COMMONWEALTH OF MASSACHUSETTS
 Department of Labor Standards
 19 Staniford Street, 2nd Floor
 Boston, MA 02114
 Phone: 617-626-6960
 Fax: 617-626-6965     Web: www.mass.gov/dols

COURSE NOTIFICATION FORM
ASBESTOS & LEAD TRAINING PROVIDERS
(In accordance with the provisions of M.G.L. c. 149, § 6-6F
and 453 CMR 6.07(3)(g), and M.G.L. c. 111, § 189A-199B and 454 CMR 22.07(5)(g))

Training Provider Information

This form must be submitted no less than 10 days prior to the beginning of the course. Please complete all sections before submitting.
Training Provider Name*:    
Authorized Provider Code*:    You must provide the accurate code assigned by DOL 
Contact Person*:     Phone*:    
Email Address*:     Fax:   

Training Course Information

Type of Training* Asbestos Course    Lead Course