Form 22806 - Application For Plumbing Contractor Examination For Licensing Page 2

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SECTION TWO

I have completed the following four (4) years of experience in the plumbing trade, satisfying the requirements as defined in commission rule, 860 IAC 1-1-9

and 860 IAC 1-1-10, as verified by employer, attached herewith:

Name of employer

Plumbing contractor license number (if applicable):

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

County

Telephone number

Dates of employment (month, day, year):

From

Name of employer

Plumbing contractor license number (if applicable):

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

County

Telephone number

Dates of employment (month, day, year):

From

APPLICANT AFFIDAVIT OF EXPERIENCE IN PLUMBING TRADE

I hereby certify that I, ____________________________________ have worked in the plumbing trade as defined in commission rule 860 IAC 1-1-9, for the

Name of applicant

period of _____________________________ to ______________________________ , for _________________________________________________.

Day, month, year

Name of company or plumbing business

Day, month, year

Name of employer or licensed plumbing contractor

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

I further certify that I am unable to obtain an employer affidavit verifying the aformentioned experience in the plumbing trade due to the following reason(s):

Signature of applicant

Date signed

NOTARY CERTIFICATE (completed by applicant)

STATE OF

}

SS:

COUNTY OF

, having been duly sworn on oath, say that I am the

above-named, that I have personally prepared the foregoing affidavit, 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