Form 22806 - Application For Plumbing Contractor Examination For Licensing Page 4
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4NOTARY CERTIFICATE (completed by applicant)
STATE OF
}
SS:
COUNTY OF
I,
, 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
Printed or typed name of Notary Public
Date subscribed and sworn to Notary Public
Date commission expires
County of residence
EMPLOYER AFFIDAVIT OF EXPERIENCE IN PLUMBING BUSINESS
I hereby certify that ______________________________________ has worked in the ___________________________________________________,
Name of applicant
Name of plumbing business
_______________________________________________, from __________________________ to ______________________ under the direction of
Address
Day and month
Day and month
____________________________________, plumbing contractor license number _____________________, said license expiring ________________.
Name of licensed plumbing contractor
Signature of licensed plumbing contractor
Date signed
Licensees who submit false information may be subject to disciplinary action by the Indiana Plumbing Commission.
NOTARY CERTIFICATE (completed by plumbing contractor)
STATE OF
}
SS:
COUNTY OF
I,
, 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 licensed plumbing contractor
Signature of Notary Public
Printed or typed name of licensed plumbing contractor
Printed or typed name of Notary Public
Date subscribed and sworn to Notary Public
Date commission expires
County of residence
SECTION FOUR (to be completed by all applicants)
NOTARY CERTIFICATE
STATE OF
}
SS:
COUNTY OF
I,
, having been duly sworn on oath, say that I am the
above-named applicant, that I have personally prepared the foregoing application, 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
Printed or typed name of Notary Public
Date subscribed and sworn to Notary Public
Date commission expires
County of residence
Page 4
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