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 CONCLUSION 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

Please make sure that all sections are completed before submittng.
Training Provider Name*:      
Authorized Provider Code*:    You must provide the accurate code assigned by DOL 
Contact Person*:     Phone*:    
E-mail Address*:     Fax:   
 CHECK HERE IF THE TRAINING LOCATION IS DIFFERENT FROM THE OFFICE LOCATION.

Asbestos or Lead Training Course

Please make sure that all sections are completed before submit.
Type of Training* Asbestos Course    Lead Course   
Name of Course*      
Start Date*:   End Date*:  
Student First Name*Student Last Name*Student Address*Certificate
Number*
Exam Score*Attach File