Free 45819.PDF - Indiana

APPLICATION FOR TEMPORARY PLUMBING CONTRACTOR'S LICENSE
State Form 45819 (R2 / 11-02) Approved by State Board of Accounts 2002

* 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 available to the Indiana Department of Revenue.

State of Indiana Indiana Professional Licensing Agency 302 W. Washington Street, Room E034 Indianapolis, Indiana 46204-2700 Telephone: (317) 232-2980 http://www.in.gov/pla

INSTRUCTIONS: 1. Please type or print. 2. $25.00 license fee + $75.00 recovery fund surcharge = $100.00 Permit Fee. 3. Make check or money order payable to: INDIANA PLUMBING COMMISSION. 1. Application will be returned if incomplete. NOTE S:

2. Your Social Security number is requested by this agency in accordance with IC 4-1-8-1; however, it is not mandatory that it be given. Social Security numbers are made available to the Department of Revenue. 3. Temporary plumbing contractor's license may be issued to an applicant who has an ownership interest in or is an offiicer of a a contracting business, if the plumbing contractor licensee operating the business has died or is physically or mentally unable to operate the business. 4. Temporary plumbing contractor's license does not enable the holder to perform actual plumbing services unless holder is a currently licensed plumbing journeyman or a currently licensed plumbing contractor. 5. The holder of a temporary license may employ a journeyman to perform actual plumbing services pursuant to the temporrary license. If the holder is a licensed journeyman, the holder may perform plumbing contracting under the authority of the temporary license. 6. A temporary license will be issued in six (6) month increments, not to exceed two (2) years.
Name of plumbing contractor company or corporate name Address (number and street, city, state, ZIP code)

LICENSURE STATUS

Telephone number ( )

1. If the plumbing contracting business is a corporation, indicate the corporation plumbing contractor license number

2. Name of deceased or physically or mentally incapacitated plumbing contractor licensee, operating the business

Plumbing contractor license number

Date of death or physical or mental incapacity

If the license holder of the business is not deceased, describe the physical or mental incapacity which is the basis for application for temporary plumbing contractor's license:

APPLICANT INFORMATION 3. Full name of applicant for teporary plumbing contractor's license (first, middle, last)
Residence address (number and street, city, state, ZIP code) If applicant is a licensed journeyman plumber, indicate license number: Date of birth (month, day, year)

Residence telephone number ( )

Social Security number *

4. If applicant is anot a licensed journeyman, please indicate the name and license number of the licensed journeyman plumber or plumbing contractor who will perform actual plumbing services pursuant to the temporary license. Name of licensed journeyman plumber or plumbing contractor License number of journeyman plumber or plumbing contractor

5. Does applicant have an ownership interest in the above named company or corporation?

6. Is applicant an officer of the above named company or corporation?

Yes

No

Yes

No

if the answer to question 6 is in the affirmative, indicate applicant's title

NOTARY CERTIFICATE STATE OF COUNTY OF

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SS:

I, 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