Asbestos Inspector, Management Planner, and Project Designer applicants only.
Project Monitor applicants complete the Asbestos Project Monitor - Work Experience Log.
A506-33AEXP-v5
Board for Asbestos, Lead and Home Inspectors/ASB EXP VER APP
03/22/2019 Page 1 of 2
Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-8595
www.dpor.virginia.gov Board for Asbestos, Lead and Home Inspectors
No Fee Required
ASBESTOS - EXPERIENCE VERIFICATION APPLICATION
Experience Verification:
Section A - should be completed by the applicant. You may duplicate this form to accommodate all your experiences.
Section B - should be completed by the supervisor or another individual who will verify the applicant's work experience. A
letter from a supervisor verifying the experience may be submitted in lieu of this Experience Verification form.
Applicants who are self-employed are required to submit a copy of three completed inspections, management plans, or
project designs (whichever is applicable for the license type) during the time frame listed below in #A.6.
Section A: Applicant
1. Applicant's Full Legal Name
(As it appears on your government issued ID or other legal documentation.)
Last (required)
First (required)
Middle Generation
Provide the last 4 digits of your identification numbers:2.
Social Security Number or
Virginia DMV Control Number
Enter the same identification number as used on examination, previous applications or licenses on file with the department.
3. Mailing Address
City State Zip Code
4. Check the one license type you are requesting:
Project Designer Management Planner Inspector
5.
Job Title (during the time of this experience)
6. Dates of Employment From:
MM/DD/YYYY
To:
MM/DD/YYYY
7. List the number of inspections, management plans, or project designs (whichever is applicable for the license type)
during the date of employment listed in question #6.
8. Provide a detailed description of your work experience:
Check here if experience was gained while self-employed.
9.
Applicant's Signature Date
I, the undersigned, certify that the foregoing statements and answers are true, and I have not suppressed any
information that might affect the decision to approve my application.
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A506-33AEXP-v5 Board for Asbestos, Lead and Home Inspectors/ASB EXP VER APP
03/22/2019
Section B: Supervisor or Verifier of Work Performance
1.
Supervisor/Verifier's Name
2.
Company/Business Name
3.
Company/Business /Verifier's Street Address
City State Zip Code
4. Contact Numbers
Primary Telephone Alternate Telephone
5. Is the information provided by the applicant correct in questions 5, 6, 7 and 8?
Yes
No
If no, please explain below.
6.
What best describes your relationship to the applicant?
Supervisor - provide a Virginia license number (if applicable)
EPA Accredited* Inspector/Management Planner/Project Designer/Project Monitor - *Attach proof of accreditation
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7. I, the undersigned, certify that the foregoing statements and answers are true.
Supervisor/Verifier's Signature Date
