747-B-99-002 Application for Individuals

Form Approved OMB No. 2070-0195 Expires 2/29/24

APPLICATION FOR INDIVIDUALS
TO CONDUCT LEAD-BASED PAINT ACTIVITIES

U.S. ENVIRONMENTAL PROTECTION AGENCY

Important: Consult the instructions provided for individuals applying for certification to conduct lead-based paint activities to complete this
form. Firms should use the Application for Firms instead of this form. Please type or print responses in black or blue ink only.

A. General Information (All applicants) Select one of the following application
types:

Official Use Only

-Initial certification application

For information on EPA and other Lead
Programs, see:
http://www.epa.gov/lead

-Re-certification application
-Adding jurisdiction[s] to certification/amending certification Replacement of a certificate

Paperwork Reduction Act: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq.
(OMB Control No. 2070-0195). Responses to this collection of information are mandatory (40 CFR 745). An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The
public reporting and recordkeeping burden for this collection of information is estimated to range from 0.5 to 3 hours per response. Send
comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for
minimizing respondent burden including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any
correspondence. Do not send the completed form to this address.

Indicate the discipline(s) for which you seek certification or re-certification and all EPA-run jurisdiction(s) in which you intend to
perform lead-based paint activities. For discipline-specific responsibilities, please see the instructions. An EPA-run jurisdiction
includes an EPA-run state, U.S. territory, or all Indian tribal land(s) in any one EPA Region. You will be eligible for certification to
work only in those EPA-run jurisdiction(s) you specify below. Attach additional sheets of paper, as necessary.
The fee you must pay depends on the number of disciplines and EPA-run jurisdiction(s) in which you plan to conduct lead-based
paint activities. See the fees schedule in the instructions to determine your fee. The total fee listed below should include fees
calculated on any additional sheets.
I=Initial

Inspector

R=Refresher

I

Supervisor

R

I

R

Risk
Assessor

Project
Designer

I

I

R

Abatement
Worker

R

I

Fee

R

$

1st EPA-run jurisdiction* (pay base certification
fee only)

$

2nd EPA-run jurisdiction*

Check here if you are listing additional EPA-run jurisdiction[s]
List each additional jurisdiction as necessary. (Each additional jurisdiction is $35 per discipline, per jurisdiction)

$

Certification exam fee ($70 each) (Does not apply to project designers, abatement workers, or applicants applying under Section C). $
Total Fee:

*See the definition of EPA-run jurisdiction[s] and the fee examples in the instructions.
For current listing of EPA-run jurisdictions, see www.epa.gov/lead, or call 1-800-424-LEAD.

$

B. Applicant Information (All applicants)
Check here if you are an employee of a Federally-recognized Indian Tribe.
Mr.

Mrs.

Ms. Name:

Last

First

Middle

Previous and/or Maiden Name(s), if applicable:
Business Phone #:

ext.

Home Phone #:

*In the event that we cannot reach you, please list another contact name and number (optional):

Home Address:

Street Address, Suite Number (Please no P.O. Box)

Company Name and Address:

Name

Street Address, Suite Number

City

State

Zip Code

City

State

Zip Code

Applicant’s E-mail Address (optional):
To which address should correspondence be sent?
EPA Form 747-B-99-002

Home

Company

Other (please attach)
Page 1 of 4

Form Approved OMB No. 2070-0195 Expires 2/29/24

Date of Birth:

Race/Ethnicity (optional):

Month/Day/Year

Country of Legal Residence:
Height:

Feet

Inches

Gender:

Weight:

Male

Eye Color:

Pounds

Female

Hair Color:

2”

Submit two identical passport photographs of you alone, recent enough to be a good
likeness (normally taken within the last 6 months). As shown in the example to the right,
photographs should be 2 x 2 inches in size with an image of your head and shoulders taking
up the majority of the area. Photographs must be clear, front view, full face, taken in normal
street clothing without a hat or dark glasses in front of a white or off-white background.
Retouched, digital, and profile images are not acceptable.

C. Reciprocity (Initial Certification applicants only)
Do you hold a current lead-based paint certification
issued by an EPA-authorized state, U.S. Territory, or Indian tribe?

Yes

No
Submit two recent
identical passport photos

If you answered Yes, please complete Section C and skip Sections D and E. Also, attach a
copy of your valid certificate and license. If you answered No, please skip Section C and
complete Sections D and E.

2”

Inspector:

State/Tribe:

Expiration Date:

Supervisor:

State/Tribe:

Expiration Date:

Risk Assessor:

State/Tribe:

Expiration Date:

Project Designer:

State/Tribe:

Expiration Date:

Abatement Worker:

State/Tribe:

Expiration Date:

D. Training (Initial and Re-certification applicants)
Answer the following items about the lead-based paint training course you received for each discipline for which you are seeking
certification or re-certification. Attach additional sheets of paper as necessary.
Discipline:
Name of Training Program:
Training Program Address:

Name of organization that taught course

Street Address, Suite Number

Training Program Phone #:

ext.

City

State

Date Training Completed:

Zip Code

Month/Day/Year

If training was conducted in a language other than English, please specify language:
Training Certificate Identification Number:
Please check the type of test you took:

EPA Form 747-B-99-002

Course test(s) and/or hands-on assessment

or

Proficiency test

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CERTIFICATION APPLICATION FOR INDIVIDUALS (CONTINUED)

Form Approved OMB No. 2070-0195 Expires 2/29/24

E. Experience and Education (Initial Certification for Supervisor, Project Designer, or Risk Assessor only)
If applying for Inspector or Worker, go to Section F.
For each discipline, check the combination you are using below:

Supervisor: (A or B must be checked.)
A.

1 year experience as certified lead abatement worker

B.

2 years experience in building trades or related field*

*Examples of related fields include lead, asbestos, environmental remediation work, or construction.

Project Designer (A or B must be checked.)
A.

Bachelors degree in engineering, architecture, or
related profession, AND
1 year experience in building construction and design
or related field*

B.

4 years experience in building construction and design
or related field*

*Examples of related fields include lead, asbestos, environmental remediation work, or construction.

Risk Assessor: (A, B, C or D must be checked.)
A.

Bachelors degree AND
1 year experience in related field*

B.

Associates degree AND
2 years experience in a related field*

C.

Certification as industrial hygienist, professional
engineer, registered architect, OR

D.

High School/GED AND
3 years experience in related field*

Certification in related engineering/health/environment
field (e.g., safety professional, environmental scientist)
*Examples of related fields include lead, asbestos, environmental remediation work, or construction.

For experience combinations checked above, answer each of the following (Attach additional sheets of paper, as necessary):
Requested Discipline:

Current Occupation Title:
Documentation attached:

Dates employed:

Company Name:
Resume

Reference Letter

Summary of work

For education checked above, answer each of the following (Attach additional sheets of paper, as necessary):
School:

Major/Course of study:

Documentation attached:

Diploma

Degree:

Year:

Transcript

F. Lead-Based Paint Activity Violations (All applicants)
Do you have any past, present, or pending lead-based paint activity violations

Yes

No

If yes, please attach a written explanation.

G. Additional Information (All applicants)
Use the following space for any additional information or comments that you feel are relevant and want EPA to consider with your
application. Attach additional sheets of paper, as necessary.

EPA Form 747-B-99-002

Page 3 of 4

CERTIFICATION APPLICATION FOR INDIVIDUALS (CONTINUED)

Form Approved OMB No. 2070-0195 Expires 2/29/24

H. Signature (All applicants)
Privacy Act Statement
Authority: 40 C.F.R. Part 745, and 15 U.S.C. §§ 2682 and 2684.
Purpose: Information collected in this system is used to establish an applicant’s eligibility for 1) certification to conduct lead-based paint and renovation, repair and
painting (RRP) activities in target housing and child-occupied facilities; and 2) accreditation to teach lead-based paint and RRP activities training courses. In addition,
certification and accreditation information, as well as information collected from required notifications are used for compliance monitoring, enforcement purposes, and
related research.
Routine Uses: EPA may disclose collected information as necessary pursuant to the routine uses published in the Privacy Act System of Records Notice: Federal
Lead-based Paint Program (FLPP) System of Records, EPA-54, F.R. 87 Fed. Reg. No. 201 (October 19, 2022), found at https://www.federalregister.gov/
documents/2022/10/19/2022-22271/privacy-act-of-1974-system-of-records. Such disclosures may include, but are not limited to, disclosure to the appropriate federal,
state, local, foreign, tribal or other public authority where relevant to the issuance or retention of a license, grant, or other benefit; to contractors, grantees, consultants,
volunteers, educational institutions, or research organizations for research purposes; or to contractors, grantees, consultants, or volunteers as necessary to perform
their duties or activities for the Agency.
Mandatory or voluntary disclosure and the effects on the individual of not providing
information: Providing your personal information is voluntary. However, failure to provide your personal information may prevent the Agency from certifying an
applicant to perform lead-based paint or RRP activities, or accrediting training programs to teach lead-based paint and RRP activities training courses.

Please sign your name and write the date in the blanks below if you understand and agree with the following statement: I hereby attest and affirm that the information
included on this application, including any attachments, is true and accurate to the best of my belief and knowledge. I acknowledge that any certification issued pursuant
to this application, including any attachments, will be subject to revocation if issuance was based on incorrect or inadequate information that materially affected the
decision to issue the certification. I also attest and affirm that I will maintain my certification(s) according to 40 CFR § 745.226, follow work practice standards according to
40 CFR § 745.227, and conduct lead-based paint activities only in those disciplines and geographical areas in which I have received certification.

Date Signed
Applicant’s Signature
(Please sign legibly within the boundaries of the box above.)

Before you mail your application and certification fee, make sure that you have:
Filled out all applicable sections of the application
Signed and dated the application
Made a copy of your application for your files
Enclosed two identical passport photos of yourself
Enclosed a copy of your course completion certificate(s) Enclosed documentation of your education, experience, and
professional certification(s), if necessary
Enclosed any other documentation needed -- see the instructions for more information
Enclosed the appropriate certification fee(s)(check or money order)
Printed “Lead Program User Fees” on the check or money order
Submitted $70 certification exam fee if applying for initial certification for Inspector, Supervisor, or Risk Assessor
For more information, see the fees section in the instructions
Mail the original completed application, supporting materials, and the certification fee to:
U.S. EPA
P.O. Box 14417
Washington, DC 20044-4417
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
2070-0195). Responses to this collection of information are mandatory (40 CFR 745). An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public
reporting and recordkeeping burden for this collection of information is estimated to be 28.5 hours per response. Send comments on the
Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing
respondent burden including through the use of automated collection techniques to the Director, Regulatory Support Division, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in
any correspondence. Do not send the completed form to this address.

EPA Form 747-B-99-002

Page 4