Page 2 must also be completed if training was taken outside Wisconsin.
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-44017 (10/2023)
STATE OF WISCONSIN
Bureau of Environmental and Occupational Health
Wis. Admin. Code ch. DHS 159
608-261-6876
ASBESTOS APPLICATION – INDIVIDUAL
Your Social Security number (SSN) is required to determine delinquency in payment of child support or state taxes, but will not be made
available to the public. If you are found delinquent, your certification will be denied under Wis. Stat. §§ 250.041 or 254.115.
APPLICANT INFORMATION
For DHS Use Only – DHS Number
Name – First
Middle
Last
Suffix (Jr, Sr, III)
Date of Birth (mm/dd/yyyy)
DHS Number (if known)
Mailing Address
City
State
Zip Code
Phone Number
Email
TRAINING List most recent training course completed. If any training taken outside Wisconsin, complete page 2.
Training Provider
Class Date
City
State
CERTIFICATION AND FEES Select your discipline and submit the corresponding fee(s).
Pay by check or money order made payable to DHS. To pay by credit or debit card, apply online at www.dhs.wi.gov/WALDO. Cash is not
accepted. Fees are nonrefundable. Additional fee for checks not honored by the bank.
Applying for:
Abatement Worker - $75
Abatement Supervisor - $125
Exterior Worker - $125 (one-time)
Exterior Supervisor - $75
Inspector - $175
Management Planner - $125
Project Designer - $175
Replacement certification card - $25
Additional requirements for out-of-state
trained applicants:
Out-of-state training processing fee - $25
Complete page 2, Additional Requirements
COMPANY INFORMATION
My asbestos company application is enclosed.
I will work for a certified asbestos company before I do any regulated work.
I currently work for the certified asbestos company listed below.
Company Name
DHS Company Number (if known)
Mailing Address
City
State
Zip Code
ENFORCEMENT ACTIONS
Within the past five years, was action taken against you for a civil or criminal violation of any federal, state, or local asbestos or other
environmental statute or regulation? Yes No
If Yes, attach documentation explaining what action was taken, why, and by whom.
SIGNATURE
I affirm that the information submitted on this application is correct. I understand that any false information provided may be grounds for
denying or revoking my certification. I understand that I must comply with Wisconsin asbestos regulations.
SIGNATURE – Applicant
Date Signed
Your provisional certification lasts until your certification card is
issued and is NOT effective until you mail this form with fee and any
required attachments to:
State of Wisconsin
PO Box 93419
Milwaukee WI 53293-3328
If you have questions, call 608-261-6876.
For DHS Use Only
DCF Check
Personal Check Company Check No.
Money Order No.
Amount Paid $ Deposit Date
F-44017 (10/2023) Page 2 of 2
ADDITIONAL REQUIREMENTS when required training was completed outside Wisconsin.
All the following are required for certification. If you have questions, call 608-261-6876.
Complete a refresher training class in Wisconsin. A list of training providers offering accredited asbestos refresher
courses is available online at www.dhs.wisconsin.gov/asbestos.
Submit COPIES of all training diplomas. Provide copies of training diplomas going back to the most recent initial class,
and every refresher since then, taken in another state. Please DO NOT SEND ORIGINAL diplomas, we cannot
guarantee their safe return. To be eligible for certification, there may be no more than 2 years between any 2
consecutive classes, dating back to your initial training.
Pay the additional $25 fee to process out-of-state training (see “Additional requirements for out-of-state trained
applicants” on page 1).
List all asbestos certifications, licenses or approvals for the discipline that were issued by another state within the past
5 years:
Type of Certification, License, or Approval
Issuing State
SIGNATURE – Applicant Date Signed
Clear/Reset Form