State Form 11812 - Application For Corporate Plumbing Contractor License - 2009

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APPLICATION FOR CORPORATE

INDIANA PROFESSIONAL LICENSING AGENCY

PLUMBING CONTRACTOR LICENSE

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

State Form 11812 (R8 / 3-09)

Telephone: (317) 234-3022

E-mail: pla10@pla.IN.gov

Approved by State Board of Accounts, 2009

INSTRUCTIONS: Please print or type.

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

* Federal ID number is requested by this agency in accordance with IC 4-1-8-1, and is mandatory that it be given. Federal ID numbers are available to the

Indiana Department of Revenue.

Name of corporation

Federal Identification number *

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

County

State of incorporation

Telephone number

E-mail address

(

)

If not Indiana, supply the date when admitted to do business

Date of incorporation or admission (month, day, year)

as foreign corporation in

Indiana (month, day, year)

Name of designated licensed plumbing contractor (corporate officer or employee)

Title of designated licensed contractor, if corporate officer

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

County

Indiana plumbing contractor license number

Telephone number

(

)

CORPORATE OFFICERS

NAMES

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

CERTIFICATION STATEMENT

We hereby certify the above information is true and correct, and that the designated plumbing contractor and officers of the plumbing corporation making

this application have not been convicted of an act which would constitute a ground for disciplinary sanction under Indiana Code 25-28.5-1-27.1, nor of

a felony that has a direct bearing on the corporation’s ability to practice plumbing competently.

We further certify, that ______________________________________________(designated plumbing contractor) has authority from the said corporation

to transact business pursuant to the license applied for herein, and agrees to be responsible for the corporation’s use of said license in accordance with

Indiana Code 25-28.5-1, which shall terminate only upon written notice to the Indiana Plumbing Commission, upon resignation, or removal from official

status in the corporation as above described.

Signature of designated plumbing contractor

Printed name of designated plumbing contractor

Date signed (month, day, year)

Signature of corporate officer

Printed name and title of corporate officer

Date signed (month, day, year)

(See back of application)