Working Together To Keep New Jersey Working
New Jersey Is An Equal Opportunity Employer
ASBESTOS CONTROL & LICENSING
(609) 633-2159
State of New Jersey
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
P.O. BOX 949
TRENTON, NJ 08625-0949
ASBESTOS CONTROL AND LICENSING ACT, N.J.S.A. 34:5A-32, ET SEQ.
APPLICATION FOR PERMIT RENEWAL
EACH APPLICANT IS REQUESTED TO VOLUNTARILY PROVIDE HIS OR HER SOCIAL SECURITY NUMBER IN HIS OR HER PERMIT
APPLICATION TO ASSIST THE COMMISSIONER IN THE ENFORCEMENT OF THE PROVISIONS OF N.J.S.A 34:5A-32 et. seq.
EACH SOCIAL SECURITY NUMBER MAY BE USED AS AN IDENTIFIER IN THE COMMISSIONER’S COMPUTERIZED
RECORDKEEPING SYSTEM TO AID IN THE PROCESSING OF PERMIT APPLICATIONS.
EACH SOCIAL SECURITY NUMBER COLLECTED SHALL REMAIN CONFIDENTIAL TO THE DEPARTMENT OF LABOR AND
WORKFORCE DEVELOPMENT.
(TYPE OR PRINT LEGIBLY IN INK, ANSWER ALL ITEMS AND PROVIDE DOCUMENTATION WHERE INDICATED ON FORM)
SOCIAL SECURITY NO.: EXPIRATION DATE:
LAST NAME: FIRST NAME: MI:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
DATE OF BIRTH: / / AGE: SEX OF APPLICANT: M/F HEIGHT:
MO / DAY / YR FEET INCHES
(0) UNDER 120 POUNDS (1) BLACK
(1) 121 TO 140 POUNDS (2) BROWN
(2) 141 TO 160 POUNDS (3) GREY
(3) 161 TO 180 POUNDS (4) BLUE
(4) 181 TO 200 POUNDS (5) HAZEL (LIGHT BROWN TO YELLOW)
(5) 201 TO 220 POUNDS (6) GREEN
WEIGHT:
CHECK
ONE
PLEASE
(6) OVER 220 POUNDS
EYE COLOR:
CHECK
ONE
PLEASE
(7) OTHER
(NOT OTHERWISE INDICATED)
HOME TELEPHONE NUMBER:
DO YOU HAVE A VALID MOTOR VEHICLE DRIVER’S LICENSE? YES NO
IF “YES” ABOVE, INDICATE STATE: DRIVER’S LICENSE NO:
I HAVE SUCCESSFULLY COMPLETED ANNUAL REFRESHER TRAINING AND I HAVE ATTACHED
DOCUMENTATION AS PROOF OF SUCH AS A:
WORKER: SUPERVISOR:
NAME OF AGENCY:
COURSE LOCATION: DATE COMPLETED: NUMBER OF HOURS: