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New York State Department of Labor Division of Safety and Health License Certification Unit Room 161A State Campus Building 12 Albany NY 12240 518 457-2735 Renewal Application For Crane Operator s Certificate of Competence 1. NYS DMV License or ID Number Print clearly MI 5. Mailing Address including city state and zip code 4. New York State Department of Labor Division of Safety and Health License Certification Unit Room 161A State Campus Building 12 Albany NY 12240 518 457-2735 Renewal Application For Crane Operator s Certificate of Competence 1. NYS DMV License or ID Number Print clearly MI 5. Mailing Address including city state and zip code 4. Certificate No* 6. Home Telephone First Name 3. Social Security No* 7. Work Telephone 8. Color of Eyes 2. Last Name 9. Color of Hair 10. Weight 11. Height FT. IN* 12. How many months of crane operating experience have you had since your last application 13. Have you been involved in any accidents while operating a crane which resulted in personal injury or property damage including damage to the crane Yes If Yes please explain No 14. a* Do you or have you ever had epilepsy or heart disease 14. b. Do you now suffer an uncorrected defect in vision 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. 15. Date 16. Signature of Applicant 6543212109876543210987654321098765432121098765432109876543210987654321210987654321098765432109876543212109876543210987654321098765432121098765432109876543210987654321 For Office Use Only 17. Remarks 18. Disposition a* Granted c* Reviewer s initials SH-847 07-08 b. d. Denied Date Prepare in Duplicate - Keep One Copy For Your Records. NYS DMV License or ID Number Print clearly MI 5. Mailing Address including city state and zip code 4. Certificate No* 6. Home Telephone First Name 3. Social Security No* 7. Work Telephone 8. Color of Eyes 2. Certificate No* 6. Home Telephone First Name 3. Social Security No* 7. Work Telephone 8. Color of Eyes 2. Last Name 9. Color of Hair 10. Weight 11. Height FT. IN* 12. How many months of crane operating experience have you had since your last application 13.

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