Renewal Application for Crane Operator’s Certificate of ...

Division of Safety and Health

License & Certification Unit

Harriman State Office Campus Building 12, Room 161A Albany, NY 12240 (518) 457-2735

Renewal Application for Crane Operator's Certificate of Competence

Print clearly

2. Last Name

First Name

5. Mailing Address (including city, state, and zip code)

1. NYS DMV License or ID Number

MI

3. Social Security No.

4. Certificate No.

6. Home Telephone

7. Work Telephone

8. Color of Eyes

9. Color of Hair

10. Weight

11. Height

FT.

IN.

12. In the last three years, I have operated a crane in my certified class for 300 hours or more.

No

Yes

13. In the last three years, have you been involved in any accidents while operating a crane which resulted in personal

injury or property damage, including damage to the crane?

No

Yes If "Yes", please explain

14. a. Do you or have you ever had epilepsy or heart disease? 14.b. Do you now suffer an uncorrected defect in vision,

No Yes

hearing or any other physical handicap? No Yes

14. c. If you answered "Yes" to either 14a or 14b, please explain

I hereby apply for renewal of my Certificate of Competence as a crane operator and certify that the information on this form is correct to the best of my knowledge.

I authorize the DOL and the DMV to produce an ID card bearing my DMV photo. I understand that DOL will send this card to the address I maintain with DOL. I also understand that DOL and DMV will use my photo to manufacture all my subsequent ID cards for as long as I maintain my license/certification with the DOL.

In order to complete this form, you must provide certain 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 the application you are filing with the Worker Protection Central Processing Unit. Failure to provide this information may result in our inability to process your application. You also understand that by signing this you are granting permission to the Commissioner of Labor to provide access to your Unemployment Insurance (U.I.) benefit file.

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a.

Granted

c. Reviewer's initials

SH 847 (04/19)

18. Disposition

b.

Denied

d. Date

Prepare in Duplicate - Keep One Copy for Your Records

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