Free 49995.PDF - Indiana

APPLICATION FOR APPROVAL OF PLUMBING APPRENTICE SCHOOL
State Form 49995 (1-01)

INDIANA PROFESSIONAL LICENSING AGENCY 302 W. Washington St., Rm. E034 Indianapolis, Indiana 46204 Telephone: (317) 232-2980 Fax: (317) 232-2312

INSTRUCTIONS: 1. Provide the school curriculum, which must include the subjects taught, and the hours spent teaching each subject. 2. No fee. 3. Use a separate sheet of paper for additional subjects and hours.
Check one:

New Application
Name of school

Annual Update
Telephone number

(
Bureau of Apprenticeship training number / program number (if applicable)

) )

School Fax number

(
Name of manager or contact person

Address of school (number and street)

City

State

ZIP code

County

SCHOOL SUBJECTS List each subject below. Hours

NOTARY CERTIFICATE I, the undersigned, submit this application in conformance with 860 IAC 2-1-7. I understand that any violations of the license laws or rules of the Indiana Plumbing Commission may cause loss of approval. I also understand that the Indiana Plumbing Commission shall be notified of any change of name, manager, contact person, or address. I certify that the information given in this application is true and correct to the best of my knowledge. STATE OF: COUNTY OF:
Signature of manager / contact person

} SS
Signature of Notary Public Printed or typed name of Notary Public

Printed or typed name of manager / contact person County of residence

Date subscribed and sworn to Notary Public

Date commission expires