Application for Certificate of Competency

The Great Seal of the State of New Jersey

New Jersey Department of Labor and Workforce Development

Division of Public Safety and Occupational Safety and Health

Bureau of Boiler and Pressure Vessel Compliance

P.O. Box 392

Trenton, New Jersey 08625-0392

Application Information
**
(First, Middle, Last)
Given name for the inspector
**
-- (xxx-xx-xxxx)
Federal identification number
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address
**
Contact number to reach inspector
(333)333-3333
**
List of grade school, high school and college education individual has
**
Name of the company or agency the applicant works for
**
(First, Middle, Last)
Name of the supervisor the applicants works under
**
contact number to reach the supervisor
(333)333-3333
The location of the company
In house assigned number provide for the Insurance carrier
Other types of certificates an applicant may hold
**
Type of certificate applicant has
**
License number of certificates held by the applicant
Name of employer history
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of employer
Type of title retained at previous employer
Type of skill performed
Number of months/years, etc applicant performed a skill
Name of employer history
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of employer
Type of title retained at previous employer
Type of skill performed
Number of months/years, etc applicant performed a skill
**
Applicant's official signature
**
**
(MM/DD/YYYY)
Date the form was completed and signed by applicant

(** indicates a required field)

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