Asbestos Certificate Application (To apply for a NYSDOL "hardcard")

For Office Use Only
Division of Safety and Health License and Certificate Unit Harriman State Office Campus Building 12, Room 161A Albany, NY 12240
Asbestos Certificate Application
You must provide personal information to complete this form. The authority to collect this information is found in the New York State Labor Law. This information will be maintained and used to process the application you are filing with the Division of Safety and Health License and Certificate Unit. Failure to provide this information may result in our inability to process your application.
Applicant’s Information
Name

First name Middle initial Last name
Social Security number
Date of birth

MonthDay Year
Date
Address

Mailing address

Street Address Line 2

City State

Zip
Home phone number
Work phone number
Email
example@example.com
NYS DMV license or ID number
Eye color
Hair color
Weight
Height (Feet)
Feet
Height (Inches)
Inches
Type of application

NewRenewal
DOH 2832 Certificate number
Asbestos Certification Requested
Check the box or boxes of each type of certificate for which you are submitting separate training documentation.
A Asbestos Handler $50D Inspector $100G Supervisor $75B Restricted Allied Trades $ 50E Management Planner $150H Project Monitor $150C Air Sampling Technician $ 75F Operations & Maintenance $ 50I Project Designer $150
Acknowledgement
- I swear the information on this form is correct to the best of my knowledge
- I am aware there are penalties for making false statements
- I agree to provide any additional documentation requested by the department
- I approve the Department of Labor (DOL) and the Department of Motor Vehicles (DMV) to produce an identification (ID) card for me using my DMV photo o I understand my DMV photo will be used for all future license and certificate ID cards o I understand the DOL will send my ID card to the mailing address given above
Applicant's Signature

Clear
Print name
Division of Safety and Health License and Certificate Unit Harriman State Office Campus Building 12, Room 161A Albany NY 12240 (518) 457-2735
www.labor.ny.gov license&certifcate@labor.ny.gov
Appendix to a License/Certificate Application
The child support obligations (New York State General Obligations Law Title 5 section 3-503) do not apply to corporations.

Complete, sign and date this form if you are applying for a license/certificate or license/certificate renewal.
Applicant’s Information
Name

First name Middle initial Last name
Social Security number
The type of license/certificate requested
Business
Title
Certification
Are you under an obligation to pay child support? If yes, complete items 1 - 4.

YesNo
1.I am making payments in accordance with a plan agreed upon by the parties.

YesNo
2.I am four months or more behind in the payment of child support.

YesNo
3.My child support obligation is the subject of a pending court proceeding.

YesNo
4.I am receiving public assistance or supplemental security income.

YesNo
If you are four months or more behind in child support or have failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding, you may be subject to suspension of your business, professional and/or driver licenses.
Affirmation
I acknowledge that giving false information is a crime and may result in this license/certificate being revoked.
Signature

Clear
Date

MonthDay Year
Date
Should be Empty:

For Office Use Only

Asbestos Certificate Application

Applicant’s Information

Asbestos Certification Requested

Acknowledgement

Appendix to a License/Certificate Application

Applicant’s Information

Certification

Affirmation