Issue link: http://iaqnet.uberflip.com/i/636984
Please do not write in this space. Approved Reason (if Disapproved): Disapproved Bates # Check # Lic # Exp. Dt. New York State Department of Labor Division of Safety and Health License and Certification Unit Harriman State Office Campus Building 12, Room 161A Albany, NY 12240 (518) 457-2735 www.labor.ny.gov Application for a Mold Remediation Contractor License Please complete and sign this form with black ink. Please print clearly. See more submittal information on page 4. _________________________________________________________________________________________________ 1. Type of License: Mold Remediation Contractor License ($500 non-refundable application fee) (check one) Mold Remediation Contractor License Renewal ($500 non-refundable application fee) License Number (Renewal only): 2. Applicant Information (please complete a through m): Business Information: a. Legal Name of Company (Must match Department of State Registration): __________________________________________________________________________________________ b. Business address P.O. Box: _________ Street (include apartment #): _______________________________________________ City, Town, Village: __________________________________________ State: ______ Zip code:____________ c. FEIN: ____________________ d. Do you operate under a Doing Business As (DBA)? Yes No If "YES", you must submit a copy of your Certificate of Doing Business Under Assumed Name ("D/B/A") for each County in which you do business. Individual Applicant's Information: e. Last name:_________________________________________________ First:______________________________________ Middle Initial:____ f. Date of birth: ____/____/________ (MM / DD / YYYY) g. NYS Driver's License or Identification Number: ____________________ h. Height (feet): ____ (inches): ____ i. Email address: ______________________________________________ j. Hair color:___________________ k. Phone: (______)____________________ l. Eye color:___________________ m. Address you want your license mailed to, if different from 2 b: P.O. Box:_________ Street (include apartment #):_________________________________________________ City, Town, Village: __________________________________________ State: ______ Zip code: ____________ 3. Training Requirement: A copy of my Mold Remediation Contractor Training Course Certificate of Completion is enclosed. Note: The Mold Remediation Contractor Training Course Certificate of Completion must be from a Department of Labor approved mold training course provider. SH 126 (12/15) Page 1 of 4