Application for a Mold Abatement Worker or Supervisor 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 Abatement Worker License or for a Mold Abatement Worker / Supervisor License. You may also use this application to renew your current license.

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 Abatement Worker / Supervisor License Renewal Mold Abatement Worker / Supervisor License, License number:

Type of License you are applying for, check one

Initial Mold Abatement Worker License Renewal Mold Abatement Worker License, License number:

Renewal Mold Abatement Worker / Supervisor License, License number

Renewal Mold Abatement Worker License, License number

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

First name

Middle initial

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

Yes

Are you under an obligation to pay child support? No If you answered Yes, complete items 1 through 4.

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.

Yes No

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.
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. I give permission to the outside sources for the disclosure of any information needed to process this application.
identification (ID) card for me using my DMV photo. oI understand my DMV photo will be used for all future license and certification ID cards oI understand the DOL will send my ID card to the mailing address given above.
work on any mold remediation project when their duties involve one or more of the following: oThe removal, cleaning, sanitizing, or surface disinfection of mold oMold containment oWaste handling of mold and materials 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

I approve the Department of Labor (DOL) and the Department of Motor Vehicles (DMV) to produce an

I swear that each person supervised by me will have his or her own valid Mold Abatement Worker License to

Applicant Signature

Clear

Date

Print Name

• oA $50.00 non-refundable application fee. Make your check or money order payable to the ‘Commissioner of Labor.’ Do not send cash.

Please complete and sign this form with black ink. Please type or print clearly.

You must include with your application:

For a Mold Abatement Worker / Supervisor License include a copy of your: ‘Mold Remediation Contractor Training Course Certificate of Completion’ form. This form must be from a New York State Department of Labor approved training provider . o For a Mold Abatement Worker License, include a copy of your: ‘ Mold Abatement Worker Training Course Certificate of Completion ’ form . This form must be from a New York State Department of Labor approved training provider
Mail the original , signed application to the New York State Department of Labor, Division of Safety and Health, License and Certificat e Unit, State Office Campus, Building 12 , Room 161A, Albany, NY 12240.
Keep a copy for your records.

Include all required documents:

Mold Abatement Note: Any individual engaged in mold abatement must have a Mold Abatement License .
Mold abatement is defined as the act of removal, cleaning, sanitizing, or surface disinfection of mold, mold containment, and waste handling of mold and materials used to remove mold from surfaces by an individual.
For individuals who will serve as site or project supervisors, a Mold Abatement Worker Supervisor’s license is required.
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 Abatement Worker or Supervisor License

Certification of Child Support Obligations

Acknowledgement

To Submit This Application:

And