Form 49995 - Application For Approval Of Plumbing Apprentice School

Download a blank fillable Form 49995 - Application For Approval Of Plumbing Apprentice School in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 49995 - Application For Approval Of Plumbing Apprentice School with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Reset Form

APPLICATION FOR APPROVAL OF

PROFESSIONAL LICENSING AGENCY

PLUMBING APPRENTICE SCHOOL

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

State Form 49995 (R / 5-09)

T elephone: (317) 234-3022

Approved by State Board of Accounts, 2009

E-mail: pla10@pla.IN.gov

FOR OFFICE USE ONLY

APPLICATION FEE

DATE FEE PAID (month, day, year)

RECEIPT NUMBER

LICENSE NUMBER

DATE OF ISSUE (month, day, year)

DO NOT WRITE ABOVE THIS LINE

Check one:

New Application

Annual Update

Name of school

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

County

Telephone number

Fax number

Bureau of Apprenticeship training number / program number (if applicable)

(

)

(

)

Name of manager or contact person

E-mail address

SCHOOL SUBJECTS

(Use a separate sheet of paper for additional subjects and hours.)

Subjects

Hours

NOTARY CERTIFICATE

I, the undersigned, submit this application in conformance with 860 IAC 2-1-7. I understand that any violations of the license laws or rules of the Indiana

Plumbing Commission may cause loss of approval. I also understand that the Indiana Plumbing Commission shall be notified of any change of name,

manager, contact person, or address. I certify that the information given in this application is true and correct to the best of my knowledge.

STATE OF:

}

COUNTY OF:

Signature of Notary Public

Signature of manager / contact person

Printed or typed name of manager / contact person

Printed or typed name of Notary Public

County of residence

Date subscribed and sworn to Notary Public (month, day, year)

Date commission expires (month, day, year)