STATE OF NEW YORK
}
COUNTY OF WESTCHESTER
}
(PRINT APPLICANT NAME)
being duly sworn, disposes and says: that he/she is the applicant above named and that the statements contained
herein are true to the best of his/her knowledge and belief.
Signature of Applicant
Applicant Sworn Before Me This
Day of
20
NOTARY PUBLIC
STATIONARY ENGINEER'S / REFRIGERATION OPERATORS'S ANNUAL LICENSE: ( CONTINUED)
LENGTH OF EMPLOYMENT
FROM: MO YR.
TOTAL:
TO: MO YR.
YRS.
MOS.
PLANT OWNER:
ADDRESS:
CITY / STATE:
PLANT TYPE:
H.P. OF HIGH PRESSURE BOILER:
TONNAGE OF REFRIGERATION SYSTEM:
NATURE OF DUTIES:
Has applicant a license elsewhere? If so, where and what kind?
Proof of employment, in writing , must accompany application. (Signed)_____________________________________Applicant
Please bring proof of license, if any, when you appear for examination.
FOR EXAMINING BOARD USE ONLY!
I hereby certify that the Board of Examiners recommends the { licensing / rejection} of the above applicant as a
{Chief Engineer} {1st Class Engineer} {2nd Class Engineer} {Refrigeration Operator}.
I hereby recommend the {granting / refusal } of a ______________________________ to the above applicant.
(Signed) _____________________________________, Examiner. Date:_________________
License No:___________________________________
Page 2 of 2
THE FOLLOWING DOCUMENTS MUST ACCOMPANY THE APPLICATION:
1. Three (3) 2x2 full face color or Black & White photographs.
2. One(1) letter of qualification and experience on printed business stationary from employer.
3. Two ( 2) character reference letters from someone other than family, co-worker and not a generic computerized letter.
4. Check or money order for the amount due payable to the City of White Plains.
a) New Application Fee $100.00.
b) Annual renewal Fee $75.00.
c) Re-Examination Fee $50.00
5. Application must be notarized.
6. A CFC Universal license is required for the Refrigeration license. ( Note: Submit original, a copy will be made when application is filed.)
7. Annual renewals are required no later than January 31st of the new year or you will be required to take the Test again.
a) Two (2) 2x2 full face color or Black & White photographs.
b) Check or money order for $50.00 payable to the City of White Plains.
