Form 8500-025 Accreditation Applicaiton for Training Programs

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

ACCREDITATION APPLICATION

U.S. ENVIRONMENTAL PROTECTION AGENCY

Important: Consult the instructions provided for training programs applying for accreditation to complete this form.
Please type or print response in black or blue ink only.

A. General Information

Official Use Only

Select one of the following application types:
Accreditation application

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

Re-accreditation application
Adding jurisdiction[s] to accreditation

Check to be listed on EPA’s web site:

Amending accreditation (check all types that apply)
New training manager

FOR TRAINING PROVIDERS

New instructor

New training location

For Evaluation and Abatement

Other

Replacement of a certificate

For Renovation

I do not want to be listed
Indicate the course[s] for which you seek accreditation or re-accreditation. List all EPA-run
jurisdiction[s] in which you intend to conduct lead-based paint activity training. An EPA-run jurisdiction includes an EPA-run state, a U.S. territory, or
all Indian tribal land[s] in any one EPA Region. Attach additional sheets of paper as necessary. EPA accreditation for renovator, and/or dust
sampling technician training is valid in all EPA-run jurisdictions (i.e., National Accreditation).
The fee you must pay depends on the number of disciplines and/or EPA-run jurisdiction[s] in which you plan to conduct lead-based paint training.
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
R=Refresher

Inspector
I
R

Supervisor
I
R

Risk
Assessor
I
R

Project
Designer
I
R

Abatement
Worker
I
R

Renovator
I
R

Dust Sampling
Technician
I
R

Fee

st

1 EPA-run jurisdiction
(pay base fee only)

$

nd

2 EPA-run jurisdiction

$
$

National Accreditation

Check here if you are listing additional EPA-run jurisdiction[s]. List each additional jurisdiction in the box below as necessary
(N/A to renovators and dust sampling technicians). Each additional jurisdiction is $35 per discipline,
per jurisdiction. See the definition of EPA-run jurisdiction[s] and the fee examples in the instructions.
For current listing of EPA-run jurisdictions, see www.epa.gov/lead, or call 1-800-424-LEAD.
Courses in electronic learning format, or a language other than English (list each course and language separately):
($

for initial course, $

for refresher course, and $

Total Fee: $

for each additional EPA-run jurisdiction per language)

Do you request a
fee waiver as a:

Local Government

State Government

Federally Recognized Indian Tribe

Nonprofit

(Nonprofit means an entity that has demonstrated to any branch of the Federal Government, or to a state, municipal, tribal, or territorial government,
that no part of its net earnings inures to the benefit of any private shareholder or individual.)

If your training program designation is nonprofit, specify the IRS-issued number below and submit a copy of an official
IRS letter confirming such designation. If another agency/state has designated your nonprofit status, indicate the
agency/state and corresponding identification number and attach appropriate documentation.
501(c)(3)

501(c)(5)
IRS-issued #

501(c)(9)
IRS-issued #

Other
IRS-issued #

B. Applicant Information
Name of Training Program & Street Address:

Business, State, Agency, etc.

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

Mailing Address:

Address

City

State

Zip Code

City

State

Zip Code

Applicant’s Phone #:
Applicant’s E-mail Address:
EPA Form 8500-25 (Rev 9/11)

ext.

Fax #:

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

Please list all types of facilities and locations at which training will take place and indicate if you plan to train at
nonpermanent facilities. Attach additional sheets of paper, as necessary.
Type of Facility

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

City

State

Zip Code

Type of Facility

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

City

State

Zip Code

Do you plan to provide training at non-permanent facilities

Yes

No

Note: A non-permanent facility is accessed by the training provider (typically through a rental or short-term lease agreement) on a one-time or
occasional basis. This would include motel facilities and other locations that serve as a temporary training location.

C. Qualifications of Training Program Manager
Name of Training Program Manager:

Last

First

Middle

Training Program Manager’s Title:
Previous and/or Maiden Name(s), if applicable:
Teaching Workers or Adults Requirement of §745.225(c)(1)(i), (ii), or (iii):
Check one of the following:
Experience

or

Education

or

Training

or

Bachelors

or graduate degree in
any field

or
Experience managing
a training program specializing in
environmental hazards

Check the supporting documentation attached for the box checked above (submit documentation with application):
Training
Bachelors
Management
Experience
Education
Experience
Certificate
Diploma
Resume
Diploma
Letter of Reference

Resume

Transcript

Transcript

Letter of Reference

Documentation of
Work Experience

Documentation of
Work Experience

Construction Industry Requirement of §745.225(c)(1)(iv):
Check one of the following:
Experience

or

Education

or

Training

Check the supporting documentation attached for the box checked above (submit documentation with application):
Experience
Education
Training
Resume

Diploma

Certificate

Letter of Reference

Transcript

Documentation of Work Experience

D. Qualifications of Principal Course Instructor (Attach a separate sheet for each individual.)
Name of Principal Course Instructor for each course:

(If more than one, attach additional sheets.)

Last

First

Middle

Previous and/or Maiden Name(s), if applicable:
Teaching Workers or Adults Requirement of §745.225(c)(2)(i):
Check one of the following:
Experience

or

Education

or

Training

Check the supporting documentation attached for the box checked above (submit documentation with application):
Experience
Education
Training
Resume

Diploma

Letter of Reference

Transcript

Documentation of Work Experience

EPA Form 8500-25 (Rev 9/11)

Certificate

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

Completion of (16 hrs) Accredited Lead-specific Training Requirement of §745.225(c)(2)(ii):
Check as many that apply and complete information for each. Attach additional sheets of paper, as necessary.
(Note: 16 hours of training are required for instructors of lead-based activities courses and 8 hours for renovator or dust sampling courses)

Discipline:

Inspector

Supervisor

Renovator (8hrs)

Risk Assessor

Project Designer

Abatement Worker

Dust Sampling Technician (8hrs)

Name of Trainer:

Name of Training Program:

Training Program Address:

Street Address, Suite Number

Training Program Phone #:

City

ext.

State

Date Training Completed:

Zip Code

Month/Day/Year

Training Certificate Identification Number:
Construction Industry Requirement of §745.225(c)(2)(iii):
Check one of the following:
Experience

or

Education

or

Training

Check the supporting documentation attached for the box checked above (submit documentation with application):
Experience
Education
Training
Resume

Diploma

Letter of Reference

Transcript

Certificate

Documentation of Work
Experience
E. Lead-Based Paint Activity or Renovation Violations
Does training Program have any past, present, or pending lead based paint activity, or renovation
violations of EPA, state, U.S. territory, or Indian tribal land(s) regulations? If yes, please attach a
written explanation.

Yes

No

F. Certification of Course Training Material
I certify that I am using th e course training materials as marked in the boxes below for each of the course s that I a m
seeking accreditation as required by §745.225(b)(1)(iii). My signature in Section I applies to this Section F.
Risk
Inspector Supervisor Assessor

Project Abatement
Dust
Designer
Worker Renovator Sampling

EPA Recommended Training Materials
Authorized State course/program
Other LBP Training
G. Re-accreditation Applicants Only
Use the following space to describe any changes to the training facility equipment or course materials since the
training program’s last application was approved. Attach additional sheets of paper as necessary.

H. Additional Information
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 8500-25 (Rev 9/11)

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

I. Certification Statement
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 Leadbased 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.
I certify that the training program described in Parts A through H of this application, including any attachments, meets the requirements established in paragraph (c) and/or (e) of 40 CFR § 745.225.
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
accreditation 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 accreditation. I also attest and affirm that I will maintain my accreditation(s) according to 40 CFR § 745.225 and conduct lead-based paint training only in those disciplines and
geographical areas in which I have received accreditation.
A false statement on this form may lead to prosecution under 18 U.S.C. 1001 or to imposition of applicable criminal and civil penalties and/or administrative remedies.\

____________________________________________
Training Manager’s Signature

__________________________/_____/_______
Date Signed

(Please print this form then sign legibly within the boundaries of the box above.)

Before you mail your application and accreditation 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 education, experience, and other documentation for the
Training Program Manager and Principal Course Instructor

Enclosed a description of facilities and equipment
Enclosed the course test blueprint

Enclosed a description of activities and procedures for hands-on skills
assessment

Enclosed quality control plan(s)

Enclosed course manual(s) and course agenda(s)
Enclosed the appropriate accreditation fee(s) (check or money order)

Printed “Lead Program User Fees” on the check or money order

For more information, review the attached application instructions.

EPA Form 8500-25 (Rev 9/11)

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.