Free VARIANCE APPLICATION - Indiana

MITCHELL E. DANIELS, Jr., Governor

STATE OF INDIANA
DEPARTMENT OF HOMELAND SECURITY J. ERIC DIETZ, EXECUTIVE DIRECTOR
Indiana Department of Homeland Security
Indiana Government Center South 302 West Washington Street Indianapolis, IN 46204 317-232-3980

Dear Applicant for Regulated Explosive Use-Blaster License: Once our department has received your completed application and verified that all requirements have been met, you will be eligible to take the examination. The testing will be done at the Indiana Government Center South, 302 W. Washington St., Indianapolis, Indiana. You will be asked to show a photo identification card at the time of testing and a minimum score of 70% is required to pass the examination. You may go to www.in.gov/dhs/training/certregsection.html to view the examination date schedule. Please call 1/800-666-7784 not sooner than ten (10) working days after sending your application to arrange a test date, time and room. Please give your full name and a phone number where you can be reached in case of a change or cancellation. You will be given a confirmation number for the class that reserves your seat and assures that the correct exam will be available for you. Sincerely,

Sue K. Sigler Registration and Certification, [email protected] 317/233-0208 or 1/800-666-7784

An Equal Opportunity Employer

APPLICATION FOR REGULATED EXPLOSIVE USE BLASTER LICENSE (675 IAC 26-2-4)
State Form 52488 (R / 3-06) Approved by State Board of Accounts, 2006

INDIANA DEPARTMENT OF HOMELAND SECURITY Registration and Certification 302 West Washington Street, E239 Indianapolis, IN 46204 Telephone: (800)666-7784 or (317) 233-0208 www.in.gov/dhs/training/certregsection.html

An applicant for licensure as a licensed regulated explosive use-blaster shall submit evidence to the Department of Homeland Security that the individual has completed an approved examination or is applying for reciprocity, is twenty-one (21) years of age, has submitted the required fee and has at least one (1) year of experience in the proper use of regulated explosives. Fee-$175.00

I am applying for certification and will be taking the examination. I am applying for certification on the basis of reciprocity in accordance with 675 IAC 26-2-4.

Attached is an original licensure document from another state or federal agency evidencing licensure under requirements that are substantially similar to the requirements of the rules of the Fire Prevention and Building Safety Commission. For purposes of reciprocity, licensure or certification by the states of Illinois, Kentucky and Ohio is deemed substantially similar.

Please Print Applicant Name: Last Address: Street E-mail: First

Last 4 digits of S.S.# Telephone Number Middle Initial Fax: City State ZIP Code

Drivers License/State ID Number Required:

I am 21 years of age or older. I have at least one (1) year experience in the proper use of explosives. I hereby affirm under penalty of perjury that all of the information provided with this application is true and correct: Signature: _________________________________________ Date: _________________________________________

APPLICATION FOR REGULATED EXPLOSIVE USE-BLASTER LICENSE (675 IAC 26-2-4) CREDIT CARD PAYMENT Payment of the fee shall be by credit card, check or money order payable to the Indiana Department of Homeland Security and must accompany this application. If paying by credit card, please fill out the form below and mail it to the above address or fax it to 317/233-0497. The application must include payment of the license fee of $175.00.
Full Name on Credit Card: _____________________________________________________________ Billing Address Street:____________________________________________________________________________ City:___________________________________ State _____________ ZIP Code _______________ Phone Number:___________________________________ Credit Card (check one): Visa MasterCard

Account Number: _____________________________________________ Expiration Date (month/year): ______ / _______ CVV2 Number (last 3 digits of the number in the signature block on the back of the card): _________ By signing, Cardmember agrees to the obligations set forth by the Cardmember's Agreement with the issuer. ______________________________________________ Signature