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Question	Answer
Form Name	Pc326 Mdr 1 Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	20
Avg. time to fill out	4 min 19 sec
Other names	mold inspection, mold inspection template blank, mold remediation invoice template, mold

12

Form Preview Example

PC326 MDR-1| Eff. 12/15/05

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CERTIFICATE OF MOLD DAMAGE REMEDIATION

Certificate Number

Date of Issuance

Name

Mailing Address

City

State

Zip

Property Description:

Number

Street

Lot

Block

Addition or Tract

City

County

SIGN APPROPRIATE CERTIFICATION

Mold Assessment Consultant License Holder Certification

∙I hereby certify that based on visual, procedural and analytical evaluation, the mold contamination identified for this project has been remediated as outlined in the mold management plan or remediation protocol.

∙I further certify with reasonable certainty that the underlying cause or causes of the mold that were identified for this project in the mold management plan or remediation protocol have been remediated. A copy of the written evaluation that forms the basis for my certification has been provided to the person named in this certificate.

Mold Assessment Consultant	Department of State Health Services	Date
License Holder Signature	License No. and Expiration Date

Mold Remediation Contractor License Holder Certification

∙I hereby certify that I completed mold remediation on this project and will provide the mold remediation certificate to the property owner no later than the 10th day after the date of completion.

Mold Remediation Contractor	Department of State Health Services	Date of Completion
License Holder Signature	License No. and Expiration Date

OR

Mold Assessment Consultant or Adjustor License Holder Certification

∙I hereby certify that I have inspected the property described in this certificate and that based on my inspection I have determined that the property does not contain evidence of mold damage. A copy of the written evaluation that forms the basis for my certification has been provided to the person named in this certificate.

Mold Assessment Consultant/Adjustor	Department of State Health Services	Date
License Holder Signature	License No. and Expiration Date

Texas Department of Insurance | www.tdi.texas.gov

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mold gaps to fill in

Write down the data in Mold, Assessment, Consultant License, Holder, Signature Department, of, State, Health, Services License, No, and, Expiration, Date Date, Mold, Remediation, Contractor License, Holder, Signature Department, of, State, Health, Services License, No, and, Expiration, Date and Date, of, Completion

Filling out mold step 2

In the Mold, Assessment, Consultant, Adjustor License, Holder, Signature Department, of, State, Health, Services License, No, and, Expiration, Date and Date area, identify the significant particulars.

step 3 to completing mold

Step 3: As soon as you are done, choose the "Done" button to export your PDF form.

Step 4: Produce a minimum of several copies of the file to keep clear of all of the future challenges.

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