Form 22806 - Application For Plumbing Contractor Examination For Licensing

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Indiana Professional Licensing Agency

APPLICATION FOR PLUMBING CONTRACTOR

302 W. Washington St., Rm. E034

EXAMINATION FOR LICENSING

Indianapolis, IN 46204-2700

State Form 22806 (R9 / 6-96)

Approved by State Board of Accounts, 1996

FEE: $30.00

ALL FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE.

Social Security number *

* 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.

Name of applicant

Date of birth (month, day, year)

Address (number and street, city, state, ZIP code)

County

Telephone number

Have you ever been convicted of a crime? (if "Yes", provide a copy of the court order and any pertinent documents)

Yes

INSTRUCTIONS:

1. If you are applying on the basis of having completed four (4) years of training in an approved apprenticeship program, please complete Sections one (1)

and four (4).

2. If you are applying on the basis of having completed four (4) years of experience in the plumbing trade, please complete Sections two (2) and (4).

3. If you are applying on the basis of having worked in the plumbing business under the direction of a licensed plumbing contractor for at least four (4)

years, please complete Sections three (3) and four (4).

SECTION ONE

I have successfully completed the following four (4) years of training in an approved apprenticeship program, satisfying the requirements as defined in

commission rule, 860 IAC 1-1-9, as verified by the sponsor of the approved apprenticeship program, herein:

Name of apprenticeship program sponsor

Telephone number

Address (number and street, city, state, ZIP code, county)

Date of enrollment (month, year)

Date of completion (month, year)

APPROVED APPRENTICESHIP PROGRAM SPONSOR CERTIFICATION OF COMPLETION

I hereby certify that

successfully

Name of apprentice

completed four (4) years of training in an approved apprenticeship program.

Date of enrollment