Free 22806.PDF - Indiana

APPLICATION FOR PLUMBING CONTRACTOR EXAMINATION FOR LICENSING
State Form 22806 (R10 / 11-02) Approved by State Board of Accounts, 2002

Indiana Professional Licensing Agency 302 W. Washington St., Rm. E034 Indianapolis, IN 46204-2700 (317)-232-2980 www.in.gov/pla

FEE: $50.00
Social Security number *

ALL FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE.
* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1; it is mandatory that it be given. Social Security numbers are made available to the Department of Revenue. Date of birth (month, day, year)

Name of applicant Address (number and street, city, state, ZIP code)

County

Telephone number

Have you ever been convicted of a crime? (if "Yes", provide a copy of the court order and any pertinent documents) Yes No

INSTRUCTIONS: 1. If you are applying on the basis of having completed four (4) years of training in an approved apprenticeship program, please complete Sections one (1) and four (4). 2. If you are applying on the basis of having completed four (4) years of experience in the plumbing trade, please complete Sections two (2) and (4). 3. If you are applying on the basis of having worked in the plumbing business under the direction of a licensed plumbing contractor for at least four (4) years, please complete Sections three (3) and four (4). SECTION ONE I have successfully completed the following four (4) years of training in an approved apprenticeship program, satisfying the requirements as defined in commission rule, 860 IAC 1-1-9, as verified by the sponsor of the approved apprenticeship program, herein:
Name of apprenticeship program sponsor Address (number and street, city, state, ZIP code, county) Telephone number

Date of enrollment (month, year)

Date of completion (month, year)

APPROVED APPRENTICESHIP PROGRAM SPONSOR CERTIFICATION OF COMPLETION I hereby certify that
Name of apprentice

successfully

completed four (4) years of training in an approved apprenticeship program.
Date of enrollment Signature of manager of approved apprenticeship program sponsor

Date of completion

Date signed

NOTARY CERTIFICATE (completed by program sponsor) STATE OF COUNTY OF I,

}

SS:

, having been duly sworn on oath, say that I am the

above-named, that I have personally prepared the foregoing affidavit, and that the same is true to the best of my knowledge and belief.
Signature of manager of approved apprenticeship program sponsor Signature of Notary Public

Printed or typed name of manager of approved apprenticeship program sponsor

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

Page 1 (continued on page 2)

SECTION TWO I have completed the following four (4) years of experience in the plumbing trade, satisfying the requirements as defined in commission rule, 860 IAC 1-1-9 and 860 IAC 1-1-10, as verified by employer, attached herewith:
Name of employer Address (number and street, city, state, ZIP code) Plumbing contractor license number (if applicable): PC

County Dates of employment (month, day, year): From Name of employer Address (number and street, city, state, ZIP code) To

Telephone number

Plumbing contractor license number (if applicable): PC

County Dates of employment (month, day, year): From To

Telephone number

APPLICANT AFFIDAVIT OF EXPERIENCE IN PLUMBING TRADE I hereby certify that I, ____________________________________ have worked in the plumbing trade as defined in commission rule 860 IAC 1-1-9, for the
Name of applicant

period of _____________________________ to ______________________________ , for _________________________________________________.
Day, month, year Day, month, year Name of company or plumbing business

Name of employer or licensed plumbing contractor

Address (number and street, city, state, Zip code) I further certify that I am unable to obtain an employer affidavit verifying the aformentioned experience in the plumbing trade due to the following reason(s):

Signature of applicant

Date signed

NOTARY CERTIFICATE (completed by applicant)

STATE OF COUNTY OF I,

}

SS:

, having been duly sworn on oath, say that I am the

above-named, that I have personally prepared the foregoing affidavit, and that the same is true to the best of my knowledge and belief.
Signature of applicant Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

EMPLOYER AFFIDAVIT OF EXPERIENCE IN PLUMBING TRADE I hereby certify that ____________________________________ has worked in the plumbing trade as defined in commission rule 860 IAC 1-1-9 for the
Name of applicant

period of _____________________________ to __________________________________.
Day, month, year Day, month, year

Signature of employer or licensed plumbing contractor Address (number and street, city, state, ZIP code)

Name of company or plumbing business

Plumbing contractor license number

Date signed

Licensees who submit false information may be subject to disciplinary action by the Indiana Plumbing Commission. Page 2 (continued on page 3)

NOTARY CERTIFICATE (completed by plumbing contractor) STATE OF COUNTY OF I,

}

SS:

, having been duly sworn on oath, say that I am the

above-named, that I have personally prepared the foregoing affidavit, and that the same is true to the best of my knowledge and belief.
Signature of employer or licensed plumbing contractor Signature of Notary Public

Printed or typed name of employer or licensed plumbing contractor

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

SECTION THREE I have worked in the following plumbing business(es) under the direction of licensed plumbing contractor(s) for at least four (4) years, satisfying the requirements as defined in commission rule, 860 IAC 1-1-9 and 860 IAC 1-1-10; as verified by licensed contractor(s).
Name of licensed plumbing contractor Address (number and street, city, state, ZIP code) License number: PC

County Dates of employment (month, day, year): From Name of licensed plumbing contractor Address (number and street, city, state, ZIP code) To

Telephone number

License number: PC

County Dates of employment (month, day, year): From To

Telephone number

APPLICANT AFFIDAVIT OF EXPERIENCE IN PLUMBING BUSINESS I hereby certify that I, __________________________________________ have worked in the ______________________________________________ ,
Name of applicant Name of plumbing business

___________________________________________________ , under the direction of ___________________________________________ , from
Address Name of licensed plumbing contractor

________________________ to __________________________.
Day, month, year Day, month, year

I further certify that I am unable to obtain an employer affidavit verifying the aforementioned work in a plumbing business under the direction of a licensed plumbing contractor due to the following reason(s):

Signature of applicant

Date signed

Page 3 (continued 0n page 4)

NOTARY CERTIFICATE (completed by applicant)

STATE OF COUNTY OF I,

}

SS:

, having been duly sworn on oath, say that I am the

above-named, that I have personally prepared the foregoing affidavit, and that the same is true to the best of my knowledge and belief.
Signature of applicant Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

EMPLOYER AFFIDAVIT OF EXPERIENCE IN PLUMBING BUSINESS I hereby certify that ______________________________________ has worked in the ___________________________________________________,
Name of applicant Name of plumbing business

_______________________________________________, from __________________________ to ______________________ under the direction of
Address Day and month Day and month

____________________________________, plumbing contractor license number _____________________, said license expiring ________________.
Name of licensed plumbing contractor

Signature of licensed plumbing contractor

Date signed

Licensees who submit false information may be subject to disciplinary action by the Indiana Plumbing Commission.

NOTARY CERTIFICATE (completed by plumbing contractor) STATE OF COUNTY OF I,

}

SS:

, having been duly sworn on oath, say that I am the

above-named, that I have personally prepared the foregoing affidavit, and that the same is true to the best of my knowledge and belief.
Signature of licensed plumbing contractor Signature of Notary Public

Printed or typed name of licensed plumbing contractor

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

SECTION FOUR (to be completed by all applicants) NOTARY CERTIFICATE STATE OF COUNTY OF I,

}

SS:

, having been duly sworn on oath, say that I am the

above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant Signature of Notary Public

Printed or typed name of applicant

Printed or typed name of Notary Public Date commission expires

Date subscribed and sworn to Notary Public

County of residence

Page 4