Form Wvdof Lsc F10 – Fill Out and Use This PDF

WVDOF-LSC-F10(4/13)

(For DOF use only)

APPLICATION FOR CERTIFIED LOGGER

West Virginia Division of Forestry

(Certification Valid for 2 years starting July 1)

Name:		Telephone: (		)

Please Print or Type

Mailing Address:

Street or Route and Box Number

Town or City

State

Zip

Social Security No:

Pursuant to Section 7 of the Privacy Act of 1974, your disclosure of your social security number is mandatory. Social security numbers are required by us for identity purposes. Failure to provide a SSN will result in your application being returned as incomplete. We have authority to solicit your social security number because of W.Va. Code §§19-1B-4,5 and/or 6.

Current Employer's Name

& Timber License Number:

(If new company or self employed please list name of company)

I hereby certify that I have satisfactorily completed the following classes conducted or approved by the West Virginia Division of Forestry in:

Best Management Practices (BMP's)	Place:
	Date:
First Aid - Proof required (Attach copy	Place:
of valid card or certificate - front & back)	Date:
Chain-Saw and Tree-Felling Safety	Place:
	Date:

SignatureDate

PRIVACY NOTICE: The WV Division of Forestry collects and processes certain personal information as needed for appropriate and customary business purposes. Personal information may be disclosed to other State agencies or third parties as necessary in the normal course of business or to comply with federal or state laws, including Freedom of Information Act requests. If you have questions