Form 8500-28 Application for Individuals to Conduct Lead-Based Paint

United States
Environmental Protection
Agency

Office of Prevention,
Pesticides, and
Toxic Substances

EPA 747-B-99-002
September 2004
http://www.epa.gov/lead

Application and
Instructions for
Individuals
Applying for Certification to Conduct
Lead-Based Paint Activities

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Clear data
Form Approved OMB No. 2070-0155 Expires 02/29/08

APPLICATION FOR INDIVIDUALS

U. S. ENVIRONMENTAL PROTECTION AGENCY

TO CONDUCT LEAD-BASED PAINT ACTIVITIES

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)

Official Use Only

Select one of the following application types:

‘
‘
‘
‘
‘
‘

Initial certification application
Re-certification application
Adding jurisdiction(s) to certification/amending certification
Replacement of a badge
Replacement of a certificate
Replacement of a badge and certificate

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

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 leadbased 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.
Inspector
I = Initial

R = Re-certification

_______________________________
1st EPA-run jurisdiction* (pay base certification fee only)
_______________________________
2nd EPA-run jurisdiction*

‘

I

Supervisor

R

I

R

Risk
Assessor
I
R

Project
Designer
R
I

Abatement
Worker
I
R

Fee

‘ ‘

‘ ‘

‘ ‘

‘ ‘

‘ ‘

$_________

‘ ‘

‘ ‘

‘ ‘

‘ ‘

‘ ‘

$_________

Check here if you are listing additional EPA-run jurisdiction(s)

(List on additional sheets of paper and attach, 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:

0.00
$_________

*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)

‘ 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, Apt. Number (Please no P.O. Box)

City

State

Zip Code

Company Name and Address: _____________________________________________________________________
Name

Street Address, Suite Number

City

State

Zip Code

Applicant’s E-mail Address (optional): ________________________________________________________________
To which address should correspondence or badge be sent? ‘ Home
Social Security #: _____-____-______ Date of Birth: ______________

‘ Company

‘ Other (please attach)

Race/Ethnicity (optional):

Month/Day/Year

Country of Legal Residence: ________________________

Gender:

Height: ____ ____

Hair Color: _______

feet

inches

EPA Form 8500-28 (Rev 09/04)

Weight: ______

Eye Color: _________

‘

Male

‘

Female

pounds

Page 1 of 4

CERTIFICATION APPLICATION FOR INDIVIDUALS (CONTINUED)

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)

2 inches

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Do you hold a current lead-based paint certification issued by an EPA-authorized
state, U.S. territory, or Indian tribe?

‘

Yes

‘

Submit two recent
identical passport photos

No

2 inches

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.
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: ________________________________________________________________________
Name of organization that taught course

Training Program Address: ________________________________________________________________________
Street Address, Suite Number

City

Training Program Phone #: (_____) _____-_______ ext. _____

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

or

‘ Proficiency test

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.

EPA Form 8500-28 (Rev 09/04)

Page 2 of 4

CERTIFICATION APPLICATION FOR INDIVIDUALS (CONTINUED)

Form Approved OMB No. 2070-0155 Expires 02/29/08

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 related field*

C ‘

Certification as industrial hygienist, professional engineer,
registered architect, OR
Certification in related engineering/health/ environment
field (e.g., safety professional, environmental scientist)

D

‘

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

*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: _____________

Dates employed: _____________
Documentation attached: ‘ Resume

Company Name: _______________

‘ 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:______________ Degree:___________ Year:_________

Documentation attached:
F.

‘ Diploma

‘ Transcript

Lead-Based Paint Activity Violations (All applicants)

Do you have any past, present, or pending lead-based paint activity violations
of EPA, state, U.S. territory, or Indian tribal land(s) regulations?

‘ 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 8500-28 (Rev 09/04)

Page 3 of 4

CERTIFICATION APPLICATION FOR INDIVIDUALS (CONTINUED)

Form Approved OMB No. 2070-0155 Expires 02/29/08

H. Signature (All applicants)
Privacy Act Statement: This statement is provided pursuant to the Privacy Act of 1974, 5 U.S.C. §552a. The authority for collecting this information is 40 C.F.R. Part 745, and 15 U.S.C.
§§2682 and 2684. The information collected on this form will be used to establish the applicant’s eligibility for certification to conduct lead-based paint activities in target housing and
child-occupied facilities. Disclosure of this information is voluntary, however, the failure to provide this information may delay or prevent an applicant’s certification. This information may
be disclosed in appropriate and limited circumstances to: EPA employees, contractors, grantees or others when performing duties that are compatible with the purpose for which this
information is collected and when this information is necessary to complete the task; a member of Congress in response to a request made with your consent and on your behalf; to
appropriate law enforcement agencies responsible for investigating, enforcing, prosecuting or implementing specific statutes, codes or regulations and this information is relevant to
that responsibility; an appropriate adjudicative body when such disclosure is compatible with the purpose for which this information is collected and the EPA or the United States has
an interest in the proceeding; and the Department of the Treasury, the General Services Administration, the General Accounting Office and other Federal, State, and Local Agencies
for authorized activities related to this information.

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
Lead User Fees

P.O. Box 979072
St. Louis, MO 63197-9000

EPA Form 8500-28 (Rev 09/04)

Page 4 of 4

INSTRUCTIONS FOR INDIVIDUALS APPLYING FOR CERTIFICATION

TO CONDUCT LEAD-BASED PAINT ACTIVITIES

You may apply to the U.S. Environmental Protection Agency (EPA) to be certified or re-certified
to conduct lead-based paint activities as an Inspector, Supervisor, Risk Assessor, Project
Designer, or Abatement Worker in states, U.S. territories, and all Indian tribal land(s) in any
one EPA Region where EPA implements the lead-based paint certification program. If EPA
does not administer the certification program in an area where you wish to work, you must apply
directly to that state, territory, or Indian tribe for certification.
These instructions supplement EPA form 8500-28 (Rev 09/04), Application for Individuals to
Conduct Lead-Based Paint Activities. Please note that you must use a separate application
form for each application type. For example, if you are applying for initial and re-certification in
two disciplines, you must use two separate application forms.
Responsibilities of Certified Disciplines
Discipline

Responsibilities

Inspector

•
•

inspection
post-abatement clearance

Supervisor

•
•
•

occupant protection plan
abatement report
oversee abatement activities

Risk Assessor

•
•
•
•

inspection
lead hazard screen
risk assessment
post-abatement clearance

Project Designer

•
•

occupant protection plan
abatement report

Abatement Worker

•

conduct abatement activities

How to Apply for Initial Certification
IF YOU ARE CURRENTLY CERTIFIED
To apply for certification from EPA if you are currently certified by an authorized state, U.S.
territory, or Indian tribe, you must:
•
•
•

•
•

Complete, sign, and date EPA form 8500-28 (Rev 09/04).
Enclose a copy of your valid certificate from an authorized state, U.S. territory, or Indian
tribe, highlighting the certification expiration date, if applicable.
Submit two identical passport photographs of you alone. Photographs must be:
<
Recent enough to be a good likeness (taken within the last 6 months);
<
Clear with a front view of your face taking up the majority of the area (hats or
dark glasses are not acceptable);

<
Focused on your head and shoulders; and

<
Printed from film with dimensions of 2 x 2 inches.

Retouched, digital, and profile images are not acceptable.

Calculate the appropriate fee using the fees schedule provided.
Print “Lead Program User Fees” on the check or money order for the fee and mail it with
your application to the address at the bottom of this page.

IF YOU ARE NOT CURRENTLY CERTIFIED
To apply for certification from EPA if you have successfully completed an EPA-accredited
training course, you must:
•
•

•
•

Complete, sign, and date EPA form 8500-28 (Rev 09/04).
Submit two identical passport photographs of you alone. Photographs must be:
<
Recent enough to be a good likeness (taken within the last 6 months);
<
Clear with a front view of your face taking up the majority of the area (hats or
dark glasses are not acceptable);

<
Focused on your head and shoulders; and

<
Printed from film with dimensions of 2 x 2 inches.

Retouched, digital, and profile images are not acceptable.

Calculate the appropriate fee using the fees schedule provided.
Print “Lead Program User Fees” on the check or money order for the fee and mail it with
your application to the address below:
U.S. EPA
Lead User Fees

P.O. Box 979072
St. Louis, MO 63197-9000

Discipline-specific Requirements
The information you must submit depends on the discipline(s) for which you seek certification.
The following table identifies these requirements.
Discipline

Application Sections

Inspector

A, B, C or D, F, G, and
H

Supervisor

A, B, C or D and E, F,
G, H

Risk Assessor*

A, B, C or D and E, F,
G, H

Required Documentation
• Valid inspector course completion certificate (Section D) or
valid certificate and license (Section C)
• Valid supervisor course completion certificate (Section D) or
valid existing certificate and license (Section C)
• Resume(s), letters of reference, etc.
• Inspector course and valid risk assessor course completion
certificates (Section D) or valid certificate and license (Section
C)
• Resume(s), letters of reference, etc.
• Official high school diploma or college transcript
• Professional certification(s)

Project Designer

A, B, C or D and E, F,
G, H

• Supervisor course and valid project designer course
completion certificates (Section D) or valid certificate and
license (Section C)
• Resume(s), letters of reference, etc.
• Official college transcript

Abatement Worker

A, B, C or D, F, G, and
H

• Valid worker course completion certificate (Section D) or valid
certificate and license (Section C)

How to Apply for Re-certification
If you completed an accredited training course with a course test and, if applicable, a hands-on
assessment, you must be re-certified every three (3) years. If you completed an accredited
course that included a proficiency test, you must be re-certified every five (5) years (all
disciplines except Project Designer).
You may take a refresher course accredited by either EPA or an EPA-authorized training
program. To ensure that you will be re-certified before your current certification expires, you
should submit your re-certification application well before your expiration date.
For re-certification, complete all sections except for sections C (Reciprocity) and E (Experience
and Education) of the application and follow the mailing instructions described in the “initial
accreditation” section of these instructions. Also submit two recent, identical passport
photographs that meet the criteria outlined on the application.
Amended Application
Amended applications must be sent to the following address:
U.S. EPA
P.O. Box 14417
Washington, DC 20044-4417

Replacement of a Identification Badge or Certificate
To replace an identification badge or certificate, complete only sections A (General Information),
B (Applicant Information), and H (Signature) of the application and follow the mailing
instructions described in the “initial accreditation” section of these instructions. For badge
replacement only, also submit two recent, identical passport photographs that meet the criteria
outlined on the application.
Incomplete Application
If your application is incomplete, EPA will not process your application. If any components of
your application are missing, your application will become inactive for a period not to exceed 30
days until the application is made complete. If you do not complete your application, EPA will
return the application package. You may apply again with a complete package. Please call 1800-424-LEAD to see if your application is complete.
Fees
The fee for applying for certification, re-certification, and other requests is listed on the following
page. It is important that you:
•
•
•
•
•
•

Calculate the fee based on the number of disciplines and number of EPA-run jurisdiction(s)
in which you plan to work.
Submit one $35 fee for all Indian tribal land(s) in any one EPA Region, if you are applying
for certification in multiple Indian tribal lands.
Include a list of the disciplines and EPA-run jurisdiction(s) with your fee, if you are applying
for certification in more than one discipline.
Write your total fee amount in section A of the application, even if you attach additional
sheets of paper listing additional EPA-run jurisdictions.
Include the certification exam fee (if applicable) with the certification fee, for more efficient
processing.
Make the check or money order payable to U.S. Environmental Protection Agency. Other
methods of payment include wire transfer, electronic funds transfer, and, for government
payers only, on-line payment agency collection (OPAC).

Fees Schedule

Certification Fee

Re-certification Fee
[every 3 or 5 years, see 40 CFR
745.226(e)(1)]

Inspector

$400

$350

Supervisor

$470

$390

Risk Assessor

$520

$420

Project Designer

$470

$390

Abatement Worker

$280

$240

Discipline

Certification examination fee*

$70 for each attempt

Multi-jurisdictional Certification Fee**

$35 per discipline for each additional EPA-run jurisdiction***

Replacement Identification Badge

$15

Replacement Certificate

$15

*Does not apply to project designers, abatement workers, or applicants applying under section C of the application

(reciprocity).

**Multi-jurisdictional certification applies to an applicant applying in more than one EPA-run jurisdiction.

***An EPA-run jurisdiction includes an EPA-run state, a U.S. territory, or all Indian tribal land(s) in any one EPA

Region. (For current listing of EPA-run jurisdictions, see www.epa.gov/lead or call 1-800-424-LEAD.)

Fee Examples
1) If applying for initial Risk Assessor certification in one state:
Initial Risk Assessor certification fee
Certification exam fee for Risk Assessor
Total Amount Due:

$ 520
$ 70
$ 590

2) If applying for initial Risk Assessor and initial Abatement Worker certifications in two states:
Initial Risk Assessor certification fee
Certification exam fee for Risk Assessor
Initial Worker certification fee (no exam fee)
One additional state fee* (2 disciplines)
Total Amount Due:

$ 520
$ 70
$ 280
$ 70
$ 940

3) If applying for initial Project Designer and initial Supervisor certifications in two states and all
Indian tribes in one EPA Region:
Initial Project Designer certification fee (no exam fee)
Initial Supervisor certification fee
Certification exam fee for Supervisor
One additional state fee* (2 disciplines)
All Indian tribes in one EPA Region fee* (2 disciplines)
Total Amount Due:
*Each certification request includes the fee for one EPA-run jurisdiction.

$ 470
$ 470
$ 70
$ 70
$ 70
$ 1150

EPA’s Certification Fees Refund Policy
Individuals having submitted an application and associated fees for certification or recertification who wish to withdraw their application prior to Agency approval will receive a fee
refund based upon the schedule listed below. Individuals who request a refund more than
10 days after the Agency receives the application will not receive a 100 percent refund.
Number of Days Following Agency Receipt of
Application

Percent Reimbursable (based upon total fees
submitted for a particular discipline)

up to 10 days

100%

11 to 60 days

75%

61 to 120 days

50%

121 or more days

25%

Note: Refunds will only be made after EPA verifies fee receipt and deposit by the U.S. Treasury.

Individuals must notify the Agency in writing in order to qualify for a refund. The date of
withdrawal is the date on which the Agency received the withdrawal notification.
EPA will not refund fees after granting an applicant certification or re-certification. Refunds are
granted only on a per discipline basis. Therefore, an individual must withdraw an application for
a particular discipline in all EPA-run jurisdiction(s) included on the application. If your
application is disapproved, EPA will not refund fees.
Refunds are not available for certification examination fees or for the replacement of an
identification badge or certificate.

Application Process
EPA processes applications on a first-come first-served basis. Your course completion
certificate will serve as interim certification for six months. If the application process is not
completed within 6 months of your course completion, the initial training must be retaken and
the application process restarted including paying the certification fee again. To make sure to
allow enough time for your application to be processed, you should submit your application for
certification to EPA within 30 days of completing your initial training course. If you are applying
for supervisor, inspector, or risk assessor certification, you must pass a 3rd party exam and
receive certification from EPA before the expiration date on your interim certification. If you do
not complete these activities before the expiration date, you cannot conduct lead-based paint
activities.
If you are applying for re-certification, your application should be submitted well before
your certification expires in order to allow time for processing. You do not need to take the
certification exam again to be re-certified.
If a firm is assisting in completing applications for individuals who are applying for
certification, please be aware of the following:
•
•
•

•
•

Individual must have an address and phone number different from the firm’s.
Individual must sign and date the application.
Individual’s name, social security number, and discipline should appear on the front of the
application fee payment (check or money order), even if it is hand-written, if the firm pays for
the individual.
EPA forwards all correspondence to individuals who have signed the application attesting to
their willingness to comply with the work practice standards found at 40 CFR §745.227.
EPA forwards copies of the individual’s approval letter and certificate to the firm upon written
request of the applicant; however, the approval letter, identification badge, and certificate
remain the property of the individual.

The flowchart on the following page depicts the application process for individual certification.

Application Process for Individual Certification

Individual submits application and fee
to EPA

Is the

application

complete?

Individual subm its
missing information

No

EPA sends letter
detailing missing
information

Yes

EPA sends the individual a letter
indicating that the application is complete

Risk Assessor, Supervisor,
and Inspector

EPA notifies the
applicant of
eligibility to take
the certification

exam

Project Designer and
Abatement Worker

Is the applicant
qualified for
certification?

Yes
Applicant takes exam

Does the applicant
pass the exam
and fulfill other
regulatory

requirements?

Yes

EPA sends
approval letter,
certificate, and
ID badge

No

EPA returns
application
with
explanation

No

Applicant may retake exam twice
within 6 months of course completion

EPA sends

approval letter,

certificate, and

ID badge

Paperwork Reduction Act Notice: The annual public burden for this collection of information is estimated to be 1
hour for inspectors, risk assessors and supervisors, and 0.5 hours for workers and project designers per response,
including the time needed for reading the instructions and completing the necessary information contained in this
form. Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden to: Director, Collection Strategies Division, Office of Environmental Information
(OEI), U.S. Environmental Protection Agency (Mail Code 2822), 1200 Pennsylvania Avenue, N.W., Washington, D.C.
20460. Include OMB number 2070-0155 in any correspondence. Do not send the completed form or requested
information to this address. The actual information or form should be submitted in accordance with the instructions
accompanying the form, or as specified in the corresponding regulations.