AFFIDAVIT - A
( Applicant )
In Support of
CERTIFICATE OF FITNESS FOR THE
SUPERVISION OF CHEMICAL LABORATORIES (C-14)
The undersigned Affiant, hereby affirms, deposes and says, under penalties of perjury, as
follows:
1. My name is _________________________________________________________________
My title is __________________________________________________________________
I will be or am assigned to work in a Laboratory located at Queensborough Community College
of the City University of New York, 222-05 56th Avenue, Bayside, NY.
2. I am requesting a Certificate of Fitness for the Supervisor of Chemical
Laboratories (“C14”) from the New York City Fire Department on the basis of my
experience of _____ years working in a laboratory consisting of:
____year(s) as a graduate student at: _____________________________________________
____year(s) as a post-doctoral fellow at: __________________________________________
____year(s) as a faculty member at: _____________________________________________
____year(s) in my current position as: ____________________________________________
3. I have received training and have reasonable understanding and knowledge of Fire Codes
2701-2703, 2706, 3RCNY 10-01, NFPA 45 (2004 edition), the Certificate of Fitness Study
Materials and my facilities’ Laboratory Safety Plan.
4. I am thoroughly familiar with the fire protection and fire suppression systems in the premises
of the Laboratory where I will be assigned.
IN WITNESS WHEREOF, the Applicant has executed this Affidavit this _____ day of
______________201___.
__________________________________
Signature of Applicant
Sworn before me this _____ day of
___________________201____.
____________________
Notary Public