Employer S Certification Form - Texas State Board Of Plumbing Examiners

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TEXAS STATE BOARD OF PLUMBING EXAMINERS
PO BOX 4200, AUSTIN, TEXAS, 78765 ▪ 512-936-5200 ▪
EMPLOYER'S CERTIFICATION FORM
Revised October 2009
In accordance with the requirements of Sections 1301.002 and 1301.354, of the Plumbing License Law, and
Board Rule Section 363.1, a person may receive credit for on-the-job work hours required to qualify for a
Tradesman Plumber-Limited or Journeyman Plumber examination, only while the person holds a valid (current
and not expired) Plumber’s Apprentice registration, or a valid Tradesman Plumber-Limited license.
1. Applicant’s Last Name ________________________________ First _________________________ MI ______
2. Mailing address ___________________________________________ City ______________________ St _____
3. Zip Code __________ Date of birth ________________________ Telephone No. ________________________
6. Social Security No. _____________________________ State Issue D.L. or I.D. No. _______________________
Disclosure of your social security number is required. Your social security number is being solicited pursuant to Texas Family Code Section 231.302
for use by the state’s Title IV-D agency to assist in the administration of laws relating to child support enforcement under 42 U.S. C Sections 601-617
and 651-669.
4.
Plumber’s Apprentice Registration No.___________ or Tradesman Plumber-Limited License No. ___________
5.
Category of registration or examination that the applicant is applying for at this time (circle one or more):
Drain Cleaner
Residential Utilities Installer
Tradesman Plumber-Limited
Journeyman Plumber
► By signing below, both the Applicant and the Responsible Master Plumber certify the above named
Applicant worked at the plumbing trade, assisting in the installation of plumbing, under the Responsible Master
Plumber’s general supervision as a Registered Plumber’s Apprentice or Tradesman Plumber-Limited Licensee,
for the period(s) shown below. The Applicant and the Responsible Master Plumber also certify the information
submitted is true and correct and understand that submitting false information to the Board may result in
criminal, monetary and/or administrative penalties to the Applicant and the Responsible Master Plumber.
DATE(S) EMPLOYED
(Supporting documentation may be required.)
FROM: MONTH
YEAR
TO
MONTH / YEAR
TOTAL HOURS
/
:
TOTAL OF HOURS LISTED ABOVE►
6. Responsible Master Plumber Name ______________________________________ License # M - ___________
7. Company Name ______________________________________________ Tel. No. (______)________________
8. Address ___________________________________________________________________________________
9. City
State
Zip _____________
10. ____________________________________________________
____________________________
Signature of Responsible Master Plumber
Date
11. ____________________________________________________
____________________________
Signature of Applicant
Date

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