Plumbing Exam Pre-Approval Request Form Page 2
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3Verification of Plumbing Work Experience and/or Local License
For TN Plumbing Exam Pre-Approval Request
SECTION A:
To be completed by Applicant
You must provide verification of at least three (3) years of plumbing work experience in order to be approved to take
the TN CMC-A or TN CMC Mechanical Plumbing Exam. In lieu of this page, you may attach a copy of W-2’s from a
plumbing contractor, or you may attach a copy of your plumbing license from another municipality. Otherwise, this
page must be completed, signed, and submitted as verification of plumbing work experience.
Plumbing Applicant Name: ____________________________________________________
Address:
________________________________________________________________
Telephone: (____) _____-_______
Cell:(____) _____-_______
Fax:(____)_____-______
Applicant Signature:____________________________________
SECTION B:
To be completed & signed by Past Employer/Contractor/Licensing Agency
The above named applicant is required to provide verification of plumbing work experience in the State of Tennessee
as a requirement in order to be approved to take the TN CMC-A or TN CMC mechanical plumbing contractor’s exam.
Our Board appreciates your assistance, time and cooperation. Please complete, sign and return this page to the
plumber applying to take the exam.
Section B completed by:
Employer/Plumber Contractor:_______________________________________________
or
______________________________
Licensing Agency
:
(County/City/Municipality Permit Office)
Type of License:
Master
Journeyman
Apprentice
Not Applicable
Other
Licensed By:
Exam - Type & Score:_____________________________ Date_________________
Endorsement- State/City/County__________________________________________
Not Applicable – State Reason:___________________________________________
Verification:
It is my opinion, to the best of my knowledge, the above named plumber applicant has the
following amount and type of plumbing work experience:
Experience:
0 – 12 months
More than 1 year
3 years or more
Type of Plumbing:
Sewage
Backflow
Connection to Potable Water
Fixtures
Water Heater
Installation of Appliances
Water Piping
Gas Piping
Sprinkler/Fire Protection
Other: _____________________________________________
Irrigation/Lawn Sprinklers
______________________________
_______________________ _________________
(SIGNATURE)
(Print Name)
(Title)
*Note: Applicants requesting pre-approval may not complete and sig n Section B themselves. Section B must be
completed and signed by the appropriate person/agency that is verifying plumbing work experience for the applicant.
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