Form Sh 125 - Application For A Mold Assessment Contractor License Page 2
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3Individual Applicant’s name: Last: _________________________________________ First: _______________________
4. Workers’ Compensation Insurance
I have workers’ compensation coverage or am exempt for the type of mold related work to be performed.
Submit a copy of one of the following forms: C-105.2, U-26.3, SI-12, GSI-105.2 or CE 200 if exempt.
If you have questions about whether your business needs to obtain a New York State Workers' Compensation
Insurance policy, please contact the Workers' Compensation Board, toll free, at (877) 632-4996.
5. Disability Insurance
I have disability insurance coverage or am exempt. Submit a copy of your Certificate of Disability Insurance
(form DB-120.1) or Certificate of Disability Self Insurance (form # DB-155) or proof of exemption form (CE-200)
with your application.
Please call the Workers’ Compensation Board, toll-free, at (877) 632-4996 if you have any questions.
6. Liability Insurance:
A copy of my Certificate of Liability Insurance is enclosed. You must submit proof that you have $50,000 in
liability insurance coverage for claims resulting from your licensed activities and operations.
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.
•
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 for mold. 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: ___________________________________
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