LEAD FIRM CERTIFICATION APPLICATION
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Lead Firm Certification Application
Instructions
NOTICE:
Please send separate payments for lead and asbestos application fees.
MDH cannot process payments that combine fees for lead and asbestos.
MDH will return applications submitted with payments that combine fees for asbestos and
lead.
Fill in the application in black or blue ink only.
Allow 2-4 weeks for processing.
Include a business check, cashier's check or money order made payable to the Minnesota
Department of Health (MDH).
No cash or personal checks accepted.
A service fee is charged for returned checks.
Fees are nonrefundable.
▪ $100 fee for lead firm certification
Mail to
Minnesota Department of Health
Asbestos/Lead Compliance Unit
St Paul, MN 55164-0497
For questions or more information, call 651-201-4620 or visit the MDH website:
https://www.health.state.mn.us/communities/environment/lead/index.html
LEAD FIRM CERTIFICATION APPLICATION
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Tennessen Warning
For individuals applying for MDH credentials
Minnesota Statute, section 270C.72, subdivision 4, requires you to submit your social security
number before MDH can issue a credential to you.
For companies applying for an MDH credential
Minnesota Statute, section 270C.72, subdivision 4, requires you to supply your Minnesota
business identification number and your social security number before MDH issues a
credential to you. Minnesota Statutes, section 176 also requires you to provide the
information concerning Workers Compensation Insurance or your permit to self-insure.
For all applicants
MDH uses the information you provide on an application to determine if you meet the
requirements for an MDH credential. You are not required to provide any of the requested
information. However, if you do not provide the requested information, MDH will be unable
to process your application. If you submit false information, MDH will deny your application
or suspend, revoke, or take other disciplinary action against your credential after issuing it.
MDH will not disclose the information on your application to others during the application
process. MDH may disclose it to others, including the Attorney General’s Office and persons
contacted for purposes of verification or investigation, if required by law. MDH will provide
information on the application, including your social security number, to the Minnesota
Department of Revenue at its request. If anyone contests your credential, the information on
your application may become public. Once MDH issues your credential, all information in the
application becomes public, except your social security number, which remains private.
LEAD FIRM CERTIFICATION APPLICATION
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Lead Firm Certification Application
Lead Firm Information
1. Company Name
2. Minnesota Business Identification Number
Required by MN Statutes, §270C.72
3. Federal Employer Identification Number
Required by MN Statutes, §270C.72
4. Business Address
5. City
6. State
7. Zip Code
8. County
9. Telephone Number ( )
10. Fax Number ( )
11. Email
12. Name of Business Contact
Workers Compensation Insurance Information
(Fill or ONLY 13 OR 14)
□ 13. Company has Workers Compensation Insurance
13a. Insurance Company
13b. Policy Number
13c. Start Date
13d. End Date
OR
LEAD FIRM CERTIFICATION APPLICATION
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□ 14. Company is exempt from Workers Compensation Insurance by MN Statutes §176
because (Check only ONE of the following)
□ I have no employees OR I have no employees working in Minnesota
□ I am self-insured
□ I have no employees who are covered by the workers compensation law
Check all that apply to be listed on MDH’s website
□ Consultant (performs paint inspections, risk assessments, clearance inspections)
Name of risk assessor License number
□ Contractor (performs lead abatement)
Name of lead supervisor License number
□ Contractor-Lead Orders (performs lead abatement for orders from MDH, City of
Minneapolis, etc.)
Name of lead supervisor License number
Signature
I provided true and complete information. I understand MDH’s Tennessen Warning, available
on page 2. I also understand that submitting false information allows MDH to deny, suspend,
revoke or take other action against this certification.
Signature Date / /
MM/DD/YYYY
