Issue link: http://iaqnet.uberflip.com/i/636984
7. Certification of Child Support Obligations Are you under an obligation to pay child support? Yes No If you answered Yes, complete items 1 - 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 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. 8. Applicant Verification Statement: This statement must be signed by the applicant or a representative of the applicant who is authorized to sign on behalf of the company or organization named in this application. A. I understand that: • This application is subject to verification and I agree to provide any additional documentation as needed. • 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. • Failure to provide any of the requested or required information may result in rejection of this application. • In order to complete this form, I must provide personal information. The authority to collect this information is found in the New York State Labor Law. This information will be maintained and used to process this application. Failure to provide this personal information may result in the inability to process my application. • The Department of Motor Vehicles will issue this license to the mailing address I maintain with the Department of Labor. B. I swear that: • Each of my employees will have his/her own valid Mold Assessor's License to work on any mold project when their duties involve the inspection or assessment of property to discover: o mold o conditions that facilitate mold o indications of conditions that are likely to encourage mold • Each of my employees will have his/her own valid Mold Abatement License to work on any mold remediation project when their duties involve one or more of the following: o the removal, cleaning, sanitizing, or surface disinfection of mold o mold containment o waste handling of mold and materials used to remove mold from surfaces • I will comply with the requirements of Article 32 of the New York State Labor Law and all the rules and regulations promulgated pursuant to Article 32 of the New York State Labor Law • The information contained in this application is accurate, true, and complete to the best of my knowledge and I am aware that there are penalties for making false statements. Applicant Signature: _____________________________________________________ Date: ___________________ Print Name: ______________________________________________ Title: ___________________________________ Page 3 of 4