NYSBOC Certification Application

NYSBOC Certification Application
Name*

First NameLast Name
Email*
example@example.com
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Are you a US Citizen?*
Are you presently employeed by a minuicpal building or code enforcement agency with NYS?*
If yes, Municipality Name
Are you an Active Member of NYSBOC*
Chapter Name
How many years have you been a member of NYSBOC?
What other building official organizations are you a member?

Certification Status
Are you currently certified by NYSBOC?*
If yes, what level are you certified to?

Certified Code InspectorCertified Code AdministratorCertified Professional Code Administrator
What level certification are you seeking?*

Certified Code InspectorCertified Code AdministratorCertified Professional Code Administrator
Have you completed the NYS Basic Training offered by NYS DOS?*
NYS Certificate No.
Certification Date

MonthDayYear
Date
Upload copy of NYS Certificate

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Verification

You may have a person who will be able to give further information for verification. If so, have them prepare and submit a letter detailing the type of work, supervisory capabilities and other relevant details. These are separate from reference letter(s).
Do you wish to submit any verification letters?*
Verification Letter

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Government Experience

Explain employment. List titles held, inclusive dates and duties of positions held for all experience areas. Copies of Civil Service job descriptions should be included when tose titles are used.
Municipality employed by:*
Department:*
Date Started*

MonthDayYear
Date
Date To*

MonthDayYear
Date
Present Title*
Civil Service Position for Present Job*
Years in this Position*
Number of persons supervised by you*
Present position duties:
Title of Previous position
Civil Service Position for Previous Job
Years in previous position
Number of persons supervised in previous position
Previous position duties
Upload Civil Service Job Descriptions

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Construction or Other Experience

List all other experience starting with the most recent, Include time worked as a supervisor or foreperson. Be sure to note if you were the owner or other person in charge of the construction of buildings, highways or other engineering projects. Include duties and duration of the projects.
Do you have any construction experience you wish to be considered?*
(1) Construction Employer
(1) Construction Supervisor

First NameLast Name
(1) Construction Date From

MonthDayYear
Date
(1) Construction Date To

MonthDayYear
Date
(1) Construction Employee Title
(1) Construction Duties
Do you have another construction experience you wish to enter?
(2) Construction Employer
(2) Construction Supervisor

First NameLast Name
(2) Construction Date From

MonthDayYear
Date
(2) Construction Date To

MonthDayYear
Date
(2) Construction Employee Title
(2) Construction Duties
Do you have any last construction experience to enter?
(3) Construction Employer
(3) Construction Supervisor

First NameLast Name
(3) Construction Date From

MonthDayYear
Date
(3) Construction Date To

MonthDayYear
Date
(3) Construction Employee Title
(3) Construction Duties

Other Qualifications

Not including construction experience...include, offices in job-related organizations, speaking engagements or articles written.
Professional License held
Licensed Issued By
License Date

MonthDayYear
Date
List any additional qualifications that would be important in determining your degree of competency

Submission
Reference Letters (2 Required)*

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I, {name}, herby submit my application for certification as a {ifYes17}. The information supplied is true to the best of my knowledge. I have taken care to provide all pertinent information that will enable the Committee to make a fair evaluation of my background.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Certification Status