Supervisor’s name, position/title, and certification number(s)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Section 4: Attachments to be submitted with the application:
a. A form of photo identification acceptable to DLS that positively establishes the identity and age of the applicant.
b. Original Asbestos training certificates, or legible copies thereof, indicating successful completion of the applicable initial and refresher
training requirements specified by 453 CMR 6.10(2), 6.10(4)(f), and/or 453 CMR 6.10(5). Original training certificates will be returned after
review of the application.
c. Current status as a registered architect or engineer with a minimum of 12 months experience in asbestos abatement fields, or
a combination of education and experience equivalent to that set forth in 453 CMR 6.07(2)(c)(1) and (2).
d. Documentation of a bachelor's degree in industrial hygiene, occupational health, or environmental, biological or physical
science.
e. A combination of education and experience equivalent to that set forth in 453 CMR 6.07(2)(c)1. and 2., as determined by the
Director. (Items C & D above).
f. A money order or certified bank check payable to the Commonwealth of Massachusetts in the amount of the entire annual fee of $625.00.
If the Director denies, revokes, suspends, or refuses to renew a certificate for reasons specified in 453 CMR 6.04, the fee payment is not
refundable.
Section 5: Payment of tax obligations and Statement of Compliance
I, ________________________________(Print name) do hereby certify, that I have complied with all laws of the Commonwealth relating
to taxes, reporting of employees and contractors, and withholding and remitting of child support (M.G.L. c. 62C, § 49A(a)), that I have read and
understand the Commonwealth of Massachusetts Regulations for The Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00,
and that all information contained herein, including any supplements attached hereto, is true and correct to the best of my knowledge and belief.
Signed under the penalties of perjury,
Signature____________________________________________________________________ Date ________________________________
Applicants for certification shall apply in person at one of the DLS offices listed below:
Monday-Walk-in service: 9am to 3pm 19 Staniford St., 2nd Floor, Boston, MA 02114617-626-6960
Tuesday-Walk-in service: 1st Tuesday of the month, 9am to 3pm 1 Federal St., Building 101, 3rd Floor, Springfield 01105413-781-2676
Wednesday-Walk-in service: 9am to 3pm 4 Summer St., Room 212, Haverhill, MA 01830978-372-9797
Thursday-Walk-in service: 2nd Thursday of the month, 9am to 3pm 1213 Purchase St., New Bedford, MA 02740 (Enter through Maxfield St.)508-984-7718
Friday- Walk-in service: 3rd Friday of the month, 9am to 3pm 167 Lyman St., Westborough, MA 01581508-616-0461
Rev 09/2016
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