GID-294-SF - Office of Insurance and Safety Fire Commissioner

www.oci.ga.govOFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONERCOMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONERRalph T. Hudgens, Commissioner2 Martin Luther King Jr., Dr., Suite 920, West Tower, Atlanta, GA 30334Phone: 404-656-2064 ◊ Fax: 404-463-0769 ◊ E-mail: engineering@sfm.ga.govAPPLICATION FOR A GEORGIA ELEVATOR MECHANIC CERTIFICATIONSAFETY FIRESAFETY ENGINEERINGGID-294-SF AUG2013(same as DOL-4262)NAMEADDRESS(Last) (First) (Initial)(Street) (City) (State) (Zip Code)HOME PHONE BUSINESS PHONE EmailEMPLOYER'S NAMEEMPLOYER'S ADDRESSScope of Certification Requested: (A minimum of three years experience is required for Certification)Class I Certification - To install, service, repair, test, maintain and perform electrical work on elevators or relatedconveyance covered by this chapter.Class II Certification - To service, repair, test and maintain elevators or other conveyance covered in this chapter.Class III Certification - To install, alter, service, repair, test, maintain and perform electrical work on residentialelevators, platform lifts and stair lifts.ELEVATOR EXPERIENCE: (A minimum of three years or experience is required)Company Name Dates Job DescriptionELEVATOR TRAININGProvider Dates DescriptionSignature of ApplicantDateThis office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document inanother format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 920, Atlanta, GA 30334 - Phone 404-656-2056.Page 1 of 2

www.oci.ga.govOFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONERAPPLICATION FOR A GEORGIA ELEVATOR MECHANIC CERTIFICATIONSAFETY FIREGID-294-SF AUG2013(same as DOL-4262)All information listed below is required to accompany the application. CHECK EACH ITEM:Certification Fee - $25.00 - Check or money order payable to:Office Of Insurance And Safety Fire Commissioner, Safety Engineering.Documentation of training and experience.Citizenship Affidavit Form GID-276-EN (Illegal Immigration Reform And Enforcement Act)Address To Remit By Mail:Office Of Insurance And Safety Fire CommissionerFire Safety Division – Safety EngineeringP.O. Box 935467Atlanta, GA 31193-5467Address To Remit By Courier:Office Of Insurance And Safety Fire CommissionerFire Safety Division – Safety EngineeringP.O. Box 935467Wells Fargo Lockbox Services3585 Atlanta Ave., Hapeville, GA 30354OFFICIAL USE ONLYCertification No.Expiration DateDate IssuedSignature of State RepresentativeThis office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document inanother format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 920, Atlanta, GA 30334 - Phone 404-656-2056.Page 2 of 2