DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY FOR L&I USE ONLY Cert #: Date: VERIFICATION OF DEGREE FOR LEAD OCCUPATION CERTIFICATION002 PLEASE TYPE OR PRINT NEATLY IN INK002 (Form cannot contain revisions, corrections or items whited-out)002 Type of Applicant Information City State Zip Code CountyNotarized Statement (Sign only in presence of a Notary) Filing Requirements PA Department of Labor & Industry 651 Boas Street, Room 1606 Harrisburg, PA 17121 002003002003Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBI-614L REV 03-18 American LegalNet, Inc. www.FormsWorkFlow.com