Application for a Mold Abatement Worker License

Application for a Mold Abatement Worker 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
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 to receiveelectronic 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 personal Mold Abatement Worker 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 (if required) and required documents.
Type of License you are applying for, check one:*

Initial Mold Abatement Worker LicenseRenewal Mold Abatement Worker License
Renewal Mold Abatement Worker License number*
Applicant’s Information, (This must be a person, not a business.)
First name*
Middle initial
Last Name*
Date of birth*

MonthDayYear
Date
Primary Phone *
NYS Department of Motor Vehicles license or Identification (ID) number*
Mailing address*
City*
State*
Zip*
Certification of Child Support Obligations
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.
  •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 givepermission 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 anidentification (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.
  •I swear that each person supervised by me will have his or her own valid Mold Abatement Worker License towork 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
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
Should be Empty:

Application for a Mold Abatement Worker License

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

Certification of Child Support Obligations

Acknowledgement