Minnesota Department of Labor and Industry Residential Building Contractors 443 Lafayette Road N. St.

Paul, MN 55155 (651) 284-5065

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Individual Application Continuing Education Course Approval

PRINT IN INK or TYPE your responses Instructions: A licensee who completes a course that has not received prior approval by the Department of Labor and Industry may submit an application and fee to request approval of the course. Approval may be granted upon a determination that the course satisfies the criteria for course accreditation. 1. Attach copy of the detailed course outline provided by the sponsor/instructor, showing the specific content of the course. If a detailed course outline is not available, you must complete the attached “Detailed content outline for individual course approval” form and attach it to your application. 2. Attach your course completion certificate, signed and dated by the instructor, identifying the course date, title, location and number of hours attended. 3. Upon review, a letter will be sent to the licensee indicating approval or denial. If approved, the letter will state the number of credits approved. Make a copy of this application for your records. APPLICATION INFORMATION LAST NAME RESIDENTIAL STREET ADDRESS LICENSE NUMBER LICENSE TYPE: building contractor roofer remodeler FIRST NAME CITY SOCIAL SECURITY NUMBER STATE ZIP CODE

DAYTIME PHONE NUMBER

COURSE INFORMATION AND FEE (Attach a check or money order payable to Department of Labor and Industry. No cash is accepted.) Date licensee attended this course Number of continuing education hrs. credits requested for this course: Individual course approval application fee: $10 COURSE TITLE SPONSOR NAME INSTRUCTOR NAME SPONSOR/INSTRUCTOR BUSINESS PHONE STATE ZIP CODE

COURSE LOCATION (name of building or facility where course was offered) CITY
Continuing education courses are required to impart substantive knowledge that is appropriate and related to the building contractor field. The burden is upon the person seeking approval or credit to demonstrate the course imparts substantive in the building contractor field.

Continuing education credit will not be approved for the following: ⌦ sales promotion, general business meetings or training primarily for marketing specific products of specific companies. ⌦ training in motivation, effective sales technique, psychology, time management or communication. ⌦ courses designed solely to prepare students for passing a license examination, time spent on meals or other unrelated activities.

1. Does this course offer building contractor training about lead abatement rules or buidling energy codes? Yes If yes, indicate number: __________ lead abatement hours requested ____________ energy code hours requested Yes No 2. Has this course been approved by the Minnesota Board of Continuing Legal Education (MNCLE)? If yes, indicate number: _________ MNCLE approved hours
(Portions of the course that impart substantive knowledge related to the contractor field may be approved for contractor continuing education.)

No

3. Has this course been approved by the regulatory agency of another state? If yes, indicate number of hours approved ____; by _____________________(name of state). Name of agency or board: ____________________________ Certification
• •

Yes

No

(Portions of the course that do not conflict with Minnesota law may be approved for Minnesota contractor continuing education.)

I certify I attended the above-named course on the date and for the number of hours listed in this application. I certify all of the information submitted in this application is true and complete, and that this document has not been changed in any manner from the form adopted by the Department of Labor and Industry. DATE

SIGNATURE OF LICENSEE (mandatory)

Office Use Only

Denied by

Approved by

Number of BC lead abatement credits approved:

Number of BC energy credits approved:

RBC 04 (1/06)

(over)

Detailed content outline for individual course approval
If the course sponsor/instructor did not provide the licensee with a detailed course outline, this form must be completed by the licensee and submitted with the individual course approval application.

Course title: Segments must be listed in increments of 15 minutes or fewer. Break times must be indicated. (Attach additional sheets if necessary). Example: Methods of valuation - Introduction Cost approach Cost approach Income approach Scheduled time 8:30 to 8:45 a.m. 8:45 to 9 a.m. 9 to 9:15 a.m. 9:15 to 9:30 a.m. Number of minutes 15 15 15 15

Total course hours: Certification

I certify that all of the information submitted in this Detailed Course Outline form is true and complete. DATE

SIGNATURE OF LICENSEE (mandatory)

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.