Application For Reinstatement Form printable pdf download

Application For Reinstatement Form

APPLICATION FOR REINSTATEMENT

ARKANSAS HVACR CONTRACTOR’S LICENSE

ARKANSAS DEPARTMENT OF HEALTH

Approved__________ 20______

PROTECTIVE HEALTH CODES

4815 W Markham SLOT H-24

By ________________________

LITTLE ROCK, ARKANSAS 72205-3867

1. NAME_________________________________________ SS#_______________________

Last

First

Middle

DOB______________________

LIC#______________________

2. FIRM NAME___________________________________________________________________

3. FIRM’S DESIGNATED LICENSE HOLDER__________________________________________

4. MAILING ADDRESS ___________________________________ PHONE# ________________

5. CITY _____________________ STATE ______ ZIP CODE ____________ COUNTY_________

6. REASON FOR LICENSE BECOMING INACTIVE:

REVOKED ______ DELINQUENT ____ DEFERRED ____ CANCELLED ___

OTHER________________________________________________________________________

______________________________________________________________________________

7. IF YOU HAVE WORKED AT THE HVACR TRADE SINCE YOUR LICENSE

BECAME INACTIVE GIVE A COMPLETE RECORD OF YOUR

EMPLOYMENT ON THE BACK OF THIS APPLICATION.

8. I HEREBY AFFIRM THAT ALL OF THE FACTS, STATEMENTS, AND

ANSWERS CONTAINED HEREIN ARE TRUE.

SIGNATURE________________________________

DATE _____________________

9. STATE OF _____________________________

COUNTY OF _____________________________

THE APPLICANT SIGNING THIS APPLICATION BEING DULY SWORN

DECLARED THAT THE FOREGOING STATEMENTS SUBSCRIBED TO BY

HIM ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND THAT

HE/SHE PERSONALLY SIGNED THIS APPLICATION.

SUBSCRIBED AND SWORN TO BEFORE ME THIS _______________ DAY OF ____________,

20 __________________.

SIGNATURE OF NOTARY _________________________________________________

Application For Reinstatement Form