Plumbing Exam Pre-Approval Request Form
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1
2
3STATE OF TENNESSEE
DEPARTMENT OF COMMERCE AND INSURANCE
BOARD FOR LICENSING CONTRACTORS
500 JAMES ROBERTSON PARKWAY, DAVY CROCKETT TOWER, 4
TH
FLOOR, NASHVILLE, TN 37243-1150
(615) 253-5741
FAX (615) 532-2868
Email:
Rhonda.M.Emanuelson@tn.gov
TN Plumbing Exam Pre-Approval Request
For TN Mechanical Plumbing (CMC/CMC-A) Exams
Pre-Approval is required by the State of Tennessee Board for Licensing Contractors in order to take the Tennessee
Mechanical Plumbing (CMC/CMC-A) Exams. Verification of at least three (3) years plumbing work experience is necessary.
RETURN ALL COMPLETED TN PLUMBING PRE-APPROVAL FORMS TO THE STATE OF TENNESSEE BOARD FOR
LICENSING CONTRACTORS. UPON APPROVAL, THE BOARD WILL NOTIFY THE APPLICANT AND PSI BY E-MAIL.
(Check One)
CMC-A (Plumbing) Exam
Applicant Information
CMC (Mechanical) Exam
Name:__________________________________ SSN*: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
*Disclosure: You are required to provide your Social Security Number (SSN). It is considered confidential and not considered a
matter of public record. (42 USC 666)
Address: ____________________________________________________________________________
____________________________________________________________________________________
City
State
Zip Code
Telephone (_____) _____-__________ Cell (_____) _____-__________ Fax (_____) _____-__________
Email Address: _______________________________________________________________________
Experience
(Attach pages 2 and 3)
1. Please attach verification from municipality/county/city permit office of plumbing work.
(pg 2)
(May attach a copy of plumbing license from another agency as evidence in lieu of verification on pg 2)
2. Are you an employee of a plumbing contractor?
No
Yes – License ID# _______________
______________________________________________
If yes, Name of Contractor:
(May attach a copy of W-2’s from a plumbing contractor as evidence in lieu of verification on pg 2)
3. Do you have an Engineering Degree in the Plumbing or Mechanical field?
No
Yes – Attach copy of documentation
– (If yes, may be approved without pg 2 & 3)
Notarize
I hereby certify, I am at least 18 years of age, have at least three (3) years plumbing work experience,
and the information submitted within this application is true and correct, to the best of my knowledge.
______________________________________
Applicant Signature
Affirmed, witnessed and subscribed before me this _______ day of _________________, 20__________
______________________________________
My Commission Expires: __________________
Notary Public Signature
For Office Use Only:
Approved
Additional Information Required
Disapproved
Other
Page 2
Page 3
Lack of Required Experience
____________
Notary
Applicant Signature
Other___________________
Other_______________________
________________________________________
Date: ______________________________
Reviewed by:
(Rev 12/14)
Page 1 of 3
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