CLE Lead Safe | Application for Risk Assessors

Page 1

Thank you for your interest in working with CHN Housing Partners. We look forward to reviewing your application and engaging with you in our lead safe initiative. Please take a few minutes to fill out the following application so we can get started working together!

 

Please note before you begin that you cannot submit a completed application without the following documentation:

  • Insurance certificate
  • Workers Comp certificate
  • State of Ohio License (RA)
  • Sample of last completed Risk Assessment (RA)
  • EPA RRP License (Contractor)

Please have these documents ready when you start your application!

LSCC Logo

Page 2 | Company Information 


Company

Company Address







Sole Proprietor

Address







Page 3 | Company Information, continued.



Primary Business Contact 




Page 4 | Company information, continued.







Page 5 | Criteria

Please list all State of Ohio Licensed Risk Assessors in your firm and attach a copy of their current license. Also list the number of prior jobs completed as indicated and provide three (3) sample copies of the most recent Risk Assessment or Clearances preformed by each risk assessor. 

Risk Assessor License Information




Minimum requirement 15 total (risk assessments, lead-based paint inspections and clearances. Some combination of all equally at least 15.








Page 6 | Certification 






Page 7 | Sign and Sumbit

Typing your name in the box below will serve as your electronic signature and as agreement to the following:

  • I certify that my answers contained in this online application are true and complete to the best of my knowledge. 
  • If this application is approved, I understand that any false or misleading information in my application may result in disqualification from the program.