NYSDOL 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.

Type of License you are applying for, check one:

Initial Mold Assessor License ($150 non-refundable application fee) Renewal Mold Assessor License ($150 non-refundable application fee), License number:

Renewal Mold Assessor License ($150 non-refundable application fee), License number

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

Name

First name Middle initial Last name

Social Security number

Date of birth

Date

Mailing address

City

State

Zip

Home phone

Work phone

Cell phone

Email

example@example.com

NYS Department of Motor Vehicles license or Identification (ID) number

No If you answered Yes, complete items 1

Are you under an obligation to pay child support? Yes

No If you answered Yes, complete items 1

Yes No

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

Yes No

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

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

Yes No

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

Yes No

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.

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

Applicant Signature

Clear

Date

Print Name

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.

• Include all required documents: o A copy of your Mold Assessor Training Course Certificate of Completion. This must be from a New York State Department of Labor approved training provider. o A letter from your employer on company letterhead verifying your employment with the company. The letter must contain the Company Mold Assessment Contractor License number

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

Application for a Mold Assessor License

Certification of Child Support Obligations

Acknowledgement

To Submit This Application:

And