Form Sh 125 - Application For A Mold Assessment Contractor License
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1
2
3Bates #
Lic #
Please do not write in this space.
Approved
Reason (if Disapproved):
Check #
Exp. Dt.
Disapproved
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
Application for a Mold Assessment Contractor License
Please note: the individual listed on this application will receive an Individual’s Mold Assessor License
Please complete and sign this form with black ink. Please print clearly. See more submittal information on page 4.
_________________________________________________________________________________________________
New ($150 non-refundable application fee)
1. Type of License:
Renewal ($150 non-refundable application fee), License Number: (Renewal Only) ___________
2. Applicant Information (please complete a through o):
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. Federal Employer Identification Number (FEIN): ____________________
d. Phone: (______)________________
e. Email: __________________________________________
Do you operate under a Doing Business As (DBA)?
Yes
No
If “YES”, you must submit a copy of your
f.
Certificate of Doing Business Under Assumed Name (“D/B/A”) for each County in which you do business.
Individual Applicant’s Information:
g. Last Name:_______________________________________ First:______________________ Middle Initial:_____
h. Individual Applicant’s Address:
P.O. Box: ___________ Street (include apartment #): ________________________________________________
City, Town, Village: __________________________________________ State: ______ Zip code:____________
NYS Driver’s License or Identification Number: ____________________
i.
Phone: (______)_________________
k. Email: ___________________________________________
j.
Date of birth: ____/____/_______(MM/DD/YYYY)
l.
m. Height (feet): ____ (inches): ____
n. Eye color: ______________
o. Hair color: ______________
3. Training Requirement:
A copy of my Mold Assessor Training Course Certificate of Completion is enclosed.
SH 125 (03/16)
Page 1 of 3
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Parent category: Legal