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K ProjectDesigner0 `  $XX $D&0` %` %&#$D X$X&# h   򀀀  z%N$6%% Ѐ**&NonUtahApprovedTrainingProvider,$25.00________(percertification)̀Lostcardreplacement,$25.00򀀀 `'4&9 @ G9/*@9( '1111!P@5 @9( '54.READANDSIGNTHEFOLLOWINGSTATEMENT:0 K Icertifythatthephotoismyimageandtheinformationprovidedinthisapplicationiscomplete,accurate,andtruetothebestofmyknowledge. K%K% 0 K 򀀀0K%K%0%%򀀀m+A*>%% 0 K 0K%K%Signature0` %%0 ` %` %0 % %0h%%0h%h%0%%Date6, +?%% @ G9ej@-+1111!(@5@-+5$< $Df@` ` !DONOTWRITEBELOWOFFICIALUSEONLY   `-4,@ 0 K      `    .,AK%K% ЀFeeReceived `    _ASB_ԄCardNumber0  0p%%򀀀DateApproved.-Bp%p% ̀InitialAccreditationValid0   󀀀ExpirationDate0p % %򀀀Photograph@0/Dp%p%  K      `     h      p      x   (# ̀RefresherAccreditationValid  򀀀󀀀Reviewer'sInitial#$D $<+# p     0 x 0 x%x%$^_ $D_DAQH_Ԅ0378027/1/02#$D _$^0#10F % % f+@/*P}QQQQQ!+@  @@1  @rr(APPLICATIONINSTRUCTIONS   X1.0  Whenfillingouttheapplicationform,printortypetherequestedinformationclearlyandlegibly.Provideallpersonalinformation $ requested.Provideacopyofpersonalphotoidentification,suchasadriverslicence,Stateorcountryidentificationcardorimmigrationidentification. && 2.0  Providebothinitialandrefreshertrainerinformation.&&   0  Sendyour originaltraining certificatesora copy ofyourtrainingcertificates,forthediscipline(s)forwhichyourare   applying.Thetrainingprovidermustbe_AHERA_Ԁaccredited.IfthisisthefirsttimeapplyingforthecertificationinUtah,submitcertificatesforyourinitialandcurrentrefreshertraining.Ifthisisarenewalcertification,submitonlyyourcurrentrefreshertrainingcertificate.Originaltrainingcertificateswillbereturned/mailedwithyourStatecertificatecard.  & & L 75h(3 L &3   &3'625h  3  .3  0    Checkwhetheryouareapplyingforinitialorrenewalcertification.Indicatedisciplinesforwhichyouareapplying. Theannual \ 0  certificationfeeis$100.00 foreachdiscipline,madepayabletotheDivisionofAirQuality. EachofyourStateasbestosdiscipline   certificationswillexpireoneyearafteryoucompletedyourmostrecenttrainingcourseforthatdiscipline .Provideeach   disciplinecertificationnumberandcard(_ASB_Ԅ)numberforrenewals. Anadditional$25.00processingfeeperdisciplinewillbe T (  chargedforallcertification(s)throughatrainingproviderifthetraingingproviderthatisnotaUtahapproved.trainingprovider. &3'6R6݌ && Ќ  4.0  SubmityoursignedandcompletedapplicationformandsupportingdocumentstotheDivision.Iftheapplicationisincomplete,itwill L  notbeprocessed.Youwillreceivedarejectletterstatingthedeficiencieswithyourapplication. && 5.0  Submita2by2inchphotographwithyournameprintedontheback.Photosmustbeafrontviewoftheperson, headandshoulder D passportqualityphotograph (nohatsordarkglasses)withanactualfacialimagefromthetopoftheheadtothebottomofthechin,  between1by13/8inches.Ifyouaresendingelectronicphotos,theymustbeatleast300by300pixelsfortherequiredarea.Photosmustbeprintedonglossypaperwithawhiteorlightcoloredbackground. Note: Snapshots,mostvendingmachineprints,Polaroids <  maynot beaccepted.Photosthathavethepersoneithertoocloseortofaraway,andprintoutsofelectronicphotoswillnotbe  accepted. && 6.0  Sendapplicationformandsupportingdocumentsto:&& 0    ExecutiveSecretary,UtahAirQualityBoard && 0    UtahDepartmentofEnvironmentalQuality && 0    DivisionofAirQuality && 0    150North1950West && 0    P.O.Box144820 && 0    SaltLakeCity,Utah841144820 &&     Phone:(801)5364000 z    *   _T.D.D._:(801)5364414 & ̀@% % & ALLOW30DAYSFORPROCESSING  * 5 @L# "5 Besurethatyouhaveincludedthefollowingitems:  }#Q"4 0  1.0 && Signedandcompletedapplicationform (call[801]5364000ifyouneedablankapplicationform);%#6 & & 0  2.0 &&A2by2inch headandshoulderpassportqualityphotograph (nohatsordarkglasses),1to13/8inchfromtopofthe &u%8 headtothebottomofthechin;ormakearrangementstohavepicturetakenattheDivisionofAirQuality.  & & 0  3.0 &&Theappropriate certificationfee(s) madepayabletoTheUtahDivisionofAirQuality;and('; & & 0  4.0 &&Theoriginaloracopyofyourinitial trainingcoursecertificate ,and/orrefreshercoursecertificate(s)asapplicable,anda m*A)= copyofyouridentificationcard.  & & @""@+*1111!CB@