Application for a Mold Remediation Contractor License

Application for a Mold Remediation Contractor 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
Note: Application for Mold Remediation Contractor no longer includes an individual license to work as a Mold Remediation Contractor. Individuals wishing to apply for or renew their individual Mold Remediation Contractor License should now use the Mold Supervisor License Application, SH127.2.
Apply Online: You can now apply for this license using the Management System for Protecting Workers’ Rights (MPWR). This completely online system speeds up the application process and makes information about applications readily available. Using MPWR, an applicant can:
•Submit their information, upload the required documentation, and pay online in one easy step.
•Receive real-time updates about the status or issues with respect to their application when they opt-in toreceive electronic communications.
•Select their preferred language.
To apply online, go to https://dol.ny.gov/mpwr and login with your personal ny.gov account and if this is your first time applying online, click on “New Request” and select the application you want. If you do not have a personal ny.gov account select the option to “Create Account.” If you experience problems creating the NY.Gov ID account, or if you are unable to sign into your NY.Gov ID account, please call 1-800-833-3000 for assistance.
Apply on Paper: Use this paper form to apply for your business’s Mold Remediation Contractor License. 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.
Note: By signing this form, you are granting permission to the commissioner of Labor to provide access to your Unemployment Insurance benefit file. Please see page 4 of this form for how to submit your application, fees and required documents.
Type of License you are applying for, check one: ($500 non-refundable application fee)*

Initial Mold Remediation Contractor LicenseRenewal Mold Remediation Contractor License
Current Mold License number*
Business’s Information Legal Name of Company (Must match Department of State Registration)*
Do you operate under a Doing Business As (DBA)?*

YesNo
If “YES”, you must submit a copy of your Certificate of Doing Business Under Assumed Name (DBA) for each County in which you do business.
Type of Business Organization:

Sole ProprietorshipLimited Liability CorporationCorporationLimited Liability PartnershipPartnershipGovernment
Federal Employer Identification Number (FEIN)
Primary Phone
Email
example@example.com
Business Physical Location
Address*
City*
State*
Zip*
Business Mailing Address (if different)
Mailing address
City
State
Zip
Designated Supervisor

All businesses must employ a licensed Mold Abatement Supervisor. Provide the name and DMV ID number of the licensed Mold Supervisor employed by your business.
Name*

First nameMiddle initialLast name
Individual Mold Supervisor License Number (If Currently Licensed):
DMV ID Number*
Certification of Child Support Obligations

(Not required for Corporations or LLCs)
Are you under an obligation to pay child support?*

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
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 a representative of the applicant who is authorized to sign on behalf of the business or organization named in this application.
•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
oI agree to provide any additional documentation as needed.
•I understand outside sources may be contacted to verify information contained in this application. Igive permission to the outside sources for the disclosure of any information needed to process thisapplication.
•I swear that each of my employees will have his or her own valid Mold Abatement License to work onany mold remediation project when their duties involve one or more of the following:
oThe removal, cleaning, sanitizing, or surface disinfection of mold containment
oWaste handling of mold and materials used to remove mold from surfaces
oMaterials used to remove mold from surfaces
•I swear that I will comply with the requirements of Article 32 of the New York State Labor Law
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
Title*
Should be Empty:

Application for a Mold Remediation Contractor License

Business Physical Location

Business Mailing Address (if different)

Designated Supervisor

Certification of Child Support Obligations

Acknowledgement