• Application for a Mold Assessor License

  • www.labor.ny.gov license&certifcate@labor.ny.gov

  • Division of Safety and Health License and Certificate Unit Harriman State Office Campus Building 12, Room 161A Albany NY 12240 (518) 457-2735

  • Use this form to apply for your personal Mold Assessor License. Note: If approved, this license is for the person listed in the ‘Applicant’s Information’ section. If you are applying for a company license please submit an Application for a Mold Assessment Contractor License, SH 125, available on our website.

    You must provide personal information to complete this form. The authority to collect this information is found in the New York State (NYS) 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.

    Please see page 2 for how to submit your application, fees and required documents.

  • Applicant’s Information, (This must be a person, not a business

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  • Certification of Child Support Obligations

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

  • Note: 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.

  • Acknowledgement

    • This statement must be signed by the applicant or the applicant’s authorized representative.
    • 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 understand that this application is subject to verification o I agree to provide any additional documentation as needed.
    • I understand outside sources may be contacted to verify information contained in this application. I give permission to the outside sources for the disclosure of any information needed to process this application.
    • 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.
    • I swear that I will comply with the requirements of Article 32 of the New York State Labor Law

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  • To Submit This Application:

    • Please complete and sign this form with black ink. Please type or print clearly.
    • You must include with your application: o The $150.00 non-refundable application fee.

    Make your check or money order payable to the ‘Commissioner of Labor.’ Do not send cash.

  • And

    • Mail the original, signed application to the New York State Department of Labor, Division of Safety and Health, License and Certificate Unit, State Office Campus, Building 12, Room 161A, Albany, NY 12240.
    • Keep a copy for your records.

    • Mold Assessment Note: Any individual engaged in mold assessment must have a Mold Assessor License and work for a company with a Mold Assessment Contractor License.
    • Mold assessment is defined as any inspection or assessment of property for the purpose to discover mold, conditions that facilitate mold, and/or any conditions that indicate they are likely to encourage mold.
    • Any business or individual that engages in mold assessment on a project, advertises that it is a mold assessment business, or holds itself out as a mold assessment business or individual must have a Mold Assessment Contractor License.
    • You must be eighteen (18) years of age or older to qualify.

    . For more information visit www.labor.ny.gov/mold

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