• 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

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  • Asbestos Certification Requested

  • Check the box or boxes of each type of certificate for which you are submitting separate training documentation.

  • 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

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  • 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

  • Certification

  • 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.

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