Form 22806 - Application For Plumbing Contractor Examination For Licensing Page 3

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NOTARY CERTIFICATE (completed by plumbing contractor)

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 employer or licensed plumbing contractor

Signature of Notary Public

Printed or typed name of employer or licensed plumbing contractor

Printed or typed name of Notary Public

Date subscribed and sworn to Notary Public

Date commission expires

County of residence

SECTION THREE

I have worked in the following plumbing business(es) under the direction of licensed plumbing contractor(s) for at least four (4) years, satisfying the

requirements as defined in commission rule, 860 IAC 1-1-9 and 860 IAC 1-1-10; as verified by licensed contractor(s).

Name of licensed plumbing contractor

License number:

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

County

Telephone number

Dates of employment (month, day, year):

From

Name of licensed plumbing contractor

License number:

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

County

Telephone number

Dates of employment (month, day, year):

From

APPLICANT AFFIDAVIT OF EXPERIENCE IN PLUMBING BUSINESS

I hereby certify that I, __________________________________________ have worked in the ______________________________________________ ,

Name of applicant

Name of plumbing business

___________________________________________________ , under the direction of ___________________________________________ , from

Address

Name of licensed plumbing contractor

________________________ to __________________________.

Day, month, year

I further certify that I am unable to obtain an employer affidavit verifying the aforementioned work in a plumbing business under the direction of a licensed plumbing contractor

due to the following reason(s):

Signature of applicant

Date signed

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