New York State Installer Certification Renewal

Complete all parts of the application. Attach any required explanations or additional information on separate sheets. Sign and date the completed form. Submit the form along with the $200.00 fee to the New York State Department of State, Division of Licensing Services, P.O. Box 22001, Albany, NY 12201-2001. For any questions, contact (518) 474-4073 or visit www.dos.ny.gov. Ensure all information provided is current, and if there are any changes, indicate them in the appropriate section of the form and attach any necessary documentation.

The form should be submitted prior to the expiration date of your current certification. Check the form and the New York State Department of State website for specific deadlines in 2024 and 2025.

The purpose of this form is to facilitate the renewal of installer certification in New York State. It ensures that applicants provide updated information and meet the regulatory requirements set forth by the state. By completing and submitting this form, certified installers can maintain their certification and continue to operate legally within the state.

• 1. Applicant's Name: Enter the full name of the individual or business applying for certification renewal.
• 2. DBA (if any): Enter the Doing Business As name, if applicable.
• 3. Street Address: Provide the street address of the applicant.
• 4. City, State, Zip: Provide the city, state, and zip code of the applicant.
• 5. Mailing Address: Provide a mailing address if it is different from the street address.
• 6. Applicant's Certification No.: Enter the current certification number of the applicant.
• 7. Individual, Trade Name, General Partnership, Corporation, LLC, LP, LLP: Check the applicable box to indicate the type of applicant.
• 8. Telephone: Provide a contact telephone number.
• 9. Fax: Provide a fax number, if available.
• 10. Email: Provide a contact email address.
• 11. Individuals listed below have certification: List the names, certification numbers, and expiration dates of limited installers employed by the applicant, if applicable.
• 12. Financial Security: Indicate the type of financial security provided and ensure it satisfies the requirements of 19 NYCRR 1210.06(a).

Failure to submit this form may result in the loss of certification and the inability to legally perform installation work in New York State.

• Loss of Certification: Your certification may become invalid if the form is not submitted.
• Legal Consequences: You may face legal consequences for performing uncertified work.
• Business Impact: Your business operations may be affected due to the lack of proper certification.

• 1. Certification Renewal: When your current certification is about to expire.
• 2. Change of Information: When there are changes in the information initially provided during certification.
• 3. Business Compliance: To ensure your business complies with New York State regulations.