Free 02557.pdf - Indiana

APPLICATION FOR OR RENEWAL OF REGISTRATION AS AN APPRENTICE PLUMBER
State Form 2557 (R9 / 9-01) Approved by State Board of Accounts, 2001

Indiana Professional Licensing Agency 302 W. Washington St., Rm. E034 Indianapolis, IN 46204-2700 Telephone: (317) 232-2980

INSTRUCTIONS: FEE: $10.00

1. Please TYPE or PRINT and complete the application in it's entirety. Incomplete applications will be returned. 2. Enclose $10.00 fee, make check or money order payable to Indiana Professional Licensing Agency. 3. Attach a copy of "APPRENTICESHIP AGREEMENT" from the Bureau of Apprenticeship Training. U.S. Department of Labor, (866 487-9243) or by certifying organization which is accepted by the Indiana Plumbing Commission. 4. The plumbing contractor / journeyman plumber by whom you are employed must complete the "EMPLOYER SECTION" of this application. APPLICANT INFORMATION

Check one: New Registration Renewal

Name of applicant

Date of birth Telephone number ( )

Address (number and street)

City, state, ZIP code

County

Social Security number *

* This agency is requesting the disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure is mandatory; this record cannot be processed without it. APPLICANT NOTARY CERTIFICATE

I hereby certify that I am learning the plumbing trade, registered in an accredited plumbing training program and attaching a copy of the "APPRENTICESHIP AGREEMENT " stating the school will timely inform the Commission of my termination from learning the plumbing trade under the auspices of said school and/or the completion of the " PROGRAM CERTIFICATION " section. I further certify that I cannot perform plumbing services without such services being performed under the direction and immediate supervision of a licensed plumbing contractor or a licensed journeyman plumber physically present on the project.
Signature of applicant Date (month, day, year)

STATE OF COUNTY OF

}

SS:

Before me, a Notary Public, personally appeared __________________________________________________ who subscribed Name of applicant and swore to the foregoing.
Signature of Notary Public Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

SCHOOL INFORMATION
Name of Commission approved school Bureau of Apprenticeship training number Method (check one)

Employer

Classroom
Source (check one)

Shop

Vocational education name: ____________________________________________________________________________ Sponsor name: ______________________________________________________________________________________ APPROVED APPRENTICESHIP PROGRAM SPONSOR CERTIFICATION I hereby certify that _____________________________________________________ is successfully enrolled in four years of training in an approved
(name of apprentice)

apprenticeship program.
Date of enrollment (month, day, year) Date signed by manager

Signature of manager of approved program sponsor

(Continued on reverse side)

APPROVED APPRENTICESHIP PROGRAM SPONSOR NOTARY CERTIFICATE

I, _____________________________________________________ , having been duly sworn on oath, say that I am the above-named approved apprenticeship program sponsor manager, that I have personally prepared the foregoing Approved Apprenticeship Program Sponsor Certification, and that the same is true to the best of my knowledge and belief.
Signature of approved apprenticeship program sponsor manager Signature of Notary Public

Printed or typed name of sponsor manager

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

County of residence of Notary Public

Date commission expires

EMPLOYMENT INFORMATION Do not use the name or license number for the Corporation. Only the individual name of responsible plumbing contractor is needed.

I, ___________________________________________________________, being a licensed plumbing contractor having license
(name of individual plumbing contractor)

number _______________________, hereby certify that I am the employer of ________________________________________
(name of applicant)

and that he/she will work under the direct and immediate supervision of a licensed plumbing contractor or licensed journeyman plumber
Signature of plumbing contractor Date signed (month, day, year)

EMPLOYER NOTARY CERTIFICATE STATE OF COUNTY OF

}

SS:

Before me, a Notary Public, personally appeared __________________________________________________ who subscribed (name of individual plumbing contractor) and swore to the foregoing.
Signature of Notary Public Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

County of residence

Date commission expires