Name: ________________________________________________

Business Address:

Street ________________________________ City ____________________ State ____ Zip _________

Phone________________________________ Fax ______________

Email address _________________________

Place and date of birth ___________________ Are you a citizen? Yes [ ] No [ ]

Are you presently employed by a municipal building or code enforcement agency within

New York State? Yes [ ] No [ ] Municipality�s Name: __________________________________

Are you an Active Member of NYSBOC? Yes [ ] No [ ] No. of years a member ______

What is the Chapter�s name? ________________________

What other building official organizations are you a member of: ______________________

__________________________________________________________________________

Certification Status:

Are you currently certified by NYSBOC? Yes [ ] No [ ] If Yes see (a); If No see (b). (a) What level are you certified to: __________________________________________________

2. What level certification are you seeking: Indicate by checking below.

Certified Professional Code Administrator ____

Have you completed the NYS basic training offered by NYS DOS Codes Division? Yes [ ] No [ ]

ID # ___________________ Date _____________ (Attach copy of NYS Certificate.)

Verification:

You may have a person who will be able to give further information for verification. If so, have them prepare and submit a letter detailing the type of work, supervisory capacities and other relevant details.
 
 

Return Completed Application and supplemental documents (original and two copies of all.) to:

Don Mekulik; Chairman - Town of Hamptonburgh, 18 Bull Rd., Campbell Hall, NY 10916   attn: Building Dept. 
 
 

Education:

High School _____________________________________from____ to_____

Graduated - Yes [ ] No [ ] GED [ ]

College _____________________________________ from____ to______

Course of study ______________________________ Degree and date received ____________

Post graduate courses _________________________

School __________________________________________from ____ to _____

Graduated - Yes [ ] No [ ] Date ______Degree ___

Other Higher Education?

Courses taken _________________________________________________

College _____________________________________ from____ to______

Dates: From ______ to ______

Other sources of learning: _____________________
 
 

Explain employment. List titles held, inclusive dates and duties of positions held for all experience areas. Copies of Civil Service job descriptions should be included when those titles are used. Use additional sheets as needed.

Government Experience:

Municipality employed by:

_____________________________________ Department: __________________________

Employed from ________ to ____________

Present title: __________________________ Years in this position ___________________

Number of persons supervised by you. _____

Duties of your present position: __________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Title of previous position: ______________________________________________________________

Number of persons supervised by you _____

Number of years in the position: _________________________________________________________

Duties:______________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Do you have Civil Service status in any of the listed positions? Yes [ ] No [ ]

List titles and grades for all civil service tests taken. __________________________________________

____________________________________________________________________________________
 
 

Other Qualifications:

Professional License(s) held: ___________________ Issued By: ____________ Dated _____________

List any additional qualifications that would be important in determining your degree of competency,

Include; offices in job-related organizations, speaking engagements or articles written.

Construction or Other Experience:

List all other experience starting with the most recent. Include time worked as a supervisor or foreperson.

Be sure to note if you were the owner or other person in charge of; the construction of buildings, highways

or other engineering projects. Include duties and duration of the projects.

Employer: ___________________________ Name of Supervisor ________________________________

Address: ____________________________________________ From ___________ To _____________

Employed as:__________________________ Duties: ________________________________________

_____________________________________________________________________________________

Employer:__________________________ Name of Supervisor: ________________________________

Address: ___________________________________________ From ___________ To _____________

Employed as: ________________________________________________________________________

____________________________________________________________________________________

Employer:__________________________ Name of Supervisor: ________________________________

Address:___________________________________________ From ___________ To _____________

Employed as:__________________________ Duties: _________________________________________

_____________________________________________________________________________________

Use additional sheets for other employers or to provide more information relating to the above sections.

I hereby submit my application for certification in the following category:_________________________

The information supplied on this form is true to the best of my knowledge. I have taken care to provide

all pertinent information that will enable the Committee to make a fair evaluation of my background.

Signed: __________________________________________________ Dated: _______________

Residing at: _____________________________________________________________________