Regulation and Licensing Department

NEW MEXICO REGULATION & LICENSING DEPARTMENT HOISTING OPERATORS SAFTEY ACT TONEY ANAYA BUILDING 2550 CERRILLOS ROAD, 3RD. FLOOR SANTA FE, NEW MEXICO 87505 TEL: (505) 476-4853 FAX: (505) 476-4511 www.rld.state.nm.us/construction/Hoisting_Program.aspx

APPLICATION FOR HOISTING OPERATOR’S LICENSE WITH IN-HOUSE TRAINING

Name Telephone (Area Code) Home Address (City) (State) (Zip) Social Security Number - - Date of Birth (mm/dd/yyyy) E-mail Address

License(s) being requested (check all boxes that apply):

Class I -- Conventional Class II -- Hydraulic

Class I -- Hydraulic Class III -- Trainee

Class I -- Tower

Written General Examination Requirements -- (must check only one box):

I have completed an approved in-house training course. A copy of my in-house training certificate is attached.

I have passed a written general examination from an approved test provider on the crane-types for which I am applying for licensure. A copy of my written examination results are attached showing a passing score of 75 percent or greater.

Note: See the Department website for approved in-house training and test providers.

Law & Safety Written Examination -- (must check box):

I have passed a written examination pertaining to the New Mexico Hoisting Operators Safety Act (NMSA-78 Articles 60-15-1 to 60-15-15) from an approved test provider. A copy of my written examination results are attached showing a passing score of 75 percent or greater.

Note: See the Department website for a list of Experience / Practical Examination Requirements --

Hoisting Operators Application with In-House Training Page 1 Rev. 05/2012 (check all boxes that apply):

I meet the experience requirements as listed below on the crane-types for which I am applying for licensing. Notarized forms documenting required experience are attached if applying for Class I or Class II licensure.

Class I: Requires a total of three (3) years work experience within the past five (5) years in operating hoisting equipment. Experience must include at least five hundred (500) hours of seat time on the specific crane-type(s) for which applying.

 Conventional: Experience must be with conventional cranes with a manufacturer's rating capacity equal to or greater than fifty (50) tons and a boom length of one hundred (100) feet.

 Hydraulic: Experience must be with hydraulic cranes with a manufacturer's rating capacity equal to or greater than 100 tons and a boom length of 100 feet

 Tower: Experience must have been with any size or type of tower crane.

Class II: Requires a total of two (2) years work experience within the past five (5) years in operating hydraulic cranes over ten (10) tons and up to one hundred (100) tons lifting capacity with a maximum boom length of one hundred fifty (150) feet, regardless of mounting or means of mobility. Experience must include at least five hundred (500) hours of seat time on the specific crane-type(s) for which applying.

Class III: No experience required.

I have passed a practical (hands-on) examination from an approved testing organization on those crane-types for which I do not meet the experience requirements. A copy of my practical examination results is attached.

Note: See the Department website for a list of approved practical examination providers. Practical examinations are not required for Class III licensure.

Physical Examination -- (must check box)

I have passed a physical examination within the last twelve (12) months of the postdate of this application conducted in accordance with U.S. Department of Transportation regulations (49 CFR 391.43). A copy of my certificate of physical examination signed by a licensed physician is attached.

Hoisting Operators Application with In-House Training Page 2 Rev. 05/2012 Substance Abuse Test -- (must check box)

I have passed a substance abuse test performed within the last twelve (12) months of the postdate of this application conducted in accordance with U.S. Department of Transportation regulations (49 CFR 40). A copy of the results of this substance abuse test signed by a Medical Review Officer (MRO) is attached.

Parental Responsibility Act -- (must check only one box)

I am listed with the New Mexico Housing Services Department as being non-compliant with a judgment and order for child support. A copy of my current Statement of Compliance from the Housing Services Department is attached.

I am not listed with the New Mexico Housing Services Department as being non-compliant with a judgment and order for child support.

Application Fees -- (must check box)

I have attached a check or money order made payable to “Hoisting Program” in the amount required by the below fee schedule.

Application Fee: $50.00 Class I License Fee: $75.00 Class II License Fee: $75.00 Class III License Fee: $25.00 Upgrade Fee: $50.00

Note: All applicants must pay the Application Fee in addition to the License Fee for the class of license being requested.

Under penalty of perjury, I swear that the information provided is true and correct to the best of my personal knowledge. I understand that my license may be subject to disciplinary action if the information given and attested to by me herein is determined to be intentionally misleading or fraudulent.

Applicant Signature Date NOTARY Signed before me the day of 20

Notary Public Signature Commission Expiration Date

Hoisting Operators Application with In-House Training Page 3 Rev. 05/2012 THIS FORM MUST BE COMPLETED BY SUPERVISOR OR EMPLOYER Note: This form is not required for those licenses where the applicant submits practical examination results in lieu of experience.

Employment Record of (Applicant Name) Employer ______

Address ______(City) (State) (Zip)

Telephone ______Manager ______(Area Code) (Print)

TYPE EMPLOYMENT BOOM # OF (Conventional, MAKE MODEL TONNAGE DATES (must be LENGTH HOURS Hydraulic or Tower) within previous 5 years) 1. From: / / To: / / 2. From: / / To: / / 3. From: / / To: / / TOTAL # OF HOURS (Hours Must Sum To 500 Hours Or More Within Previous Five (5) Years) Under penalty of perjury, I swear that in making this certification, I have not relied on statements made to me by the Applicant or third party(ies), and that the information provided in this certification is true and correct to the best of my personal knowledge.

Employer/Supervisor Signature Title

Print Name Date

NOTARY

Signed before me the day of 20

Notary Public Signature Commission Expiration Date

IF NECESSARY, PHOTOCOPY THIS PAGE AND ATTACH ADDITIONAL SHEETS. Hoisting Operators Application In-House Training Page 4 Rev. 01.2012 CHECK THE APPROPRIATE BOX(ES) FOR PREVIOUS FIVE (5) YEAR EXPERIENCE Note: This form is not required for those licenses where the applicant submits practical examination results in lieu of experience.

Hydraulic Cranes

Mechanic Trucks Through 10 tons Boom Trucks Through 100 tons RT Through 100 tons RT Over 100 tons HYD-Crawler Through 100 tons HYD Through 100 tons HYD Above 100 tons Conventional Cranes

Crawler Through 50 tons Crawler Over 50 tons Wheel Mounted Under 50 tons Wheel Mounted Over 50 tons Tower Cranes

Crawler or Truck with Tower Attachment Free Standing or other Tower Cranes

In making this certification, I swear under penalty of perjury, that the information provided is true and correct to the best of my personal knowledge. I understand that my license may be subject to disciplinary action if the information given and attested to by me herein is determined to be intentionally misleading or fraudulent.

Applicant Signature Date

NOTARY

Signed before me the day of 20

Notary Public Signature Commission Expiration Date Approved Law & Safety Examination Providers. BE SURE YOUR APPLICATION IS COMPLETE AND THAT THE FOLLOWING ITEMS ARE INCLUDED:

1. Page four of your application must be completed by your supervisor/employer .

Hoisting Operators Application In-House Training Page 5 Rev. 01.2012 Page 3 and 4 must be notarized. Page 4 must verify the following:

a. Your specific dates of employment. NOTE: Class I requires a total of 3 year work experience within the past 5 and, Class II requires a total of 2 years work experience within the past 5 years. b. Type(s) of hoisting equipment operated. c. Number of specific hours of operation of each type of equipment. d. Total hours of operation of 500 hours or more of seat time on the appropriate type of equipment for which you are applying. e. Tonnage of hoisting equipment operated. f. Your supervisor’s notarized signature.

2. A signed and notarized document for proof of compliance with the Parental Responsibility Act, if applicable.

3. Application and License fee is $125.00. (No Credit Cards Accepted).

4. Make your check payable to the: Hoisting Program.

5. Certificate of your Physical Examination (Note: Must be current and signed by an MRO (Medical Review Officer aka licensed physician) and not the person that withdrew the blood work for you.

7. Drug Screening Report. (NOTE: Your Drug Screening Report is NOT the same as your Physical Exam and must be included with this application). The medical card must be within the last twelve (12) months. It must be signed by your Doctor or an MRO and it must indicate that your results are negative. It also must show that you have passed a DOT like Drug Screen within the last twelve (12) months. Applications will not be accepted without this information.

8. Copy of both sides of your current certification card.

9. The attached (and original) affidavit stating you have read and agree to comply with the New Mexico Hoisting Operators Safety Act and its Rule

Hoisting Operators Application In-House Training Page 5 Rev. 01.2012