State Form 2557 - Application For Registration As An Apprentice Plumber
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APPLICATION FOR REGISTRATION AS AN
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
APPRENTICE PLUMBER
Indianapolis, Indiana 46204
State Form 2557 (R10 / 6-10)
T elephone: (317) 234-3022
Approved by State Board of Accounts, 2010
E-mail: pla10@pla.IN.gov
* Your Social Security number is being requested by this state agency in accordance with Indiana Code. Disclosure is mandatory, and this record cannot be processed without it.
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
APPLICANT INFORMATION
Name of applicant (
)
Social Security number *
Address (
)
Date of birth (
)
Place of birth (
)
Telephone number (
)
E-mail address
(
)
APPROVED APPRENTICESHIP PROGRAM SPONSOR CERTIFICATION
I hereby certify that _____________________________________________________ is currently enrolled in our four (4) year apprenticeship program.
I hereby swear of affirm, under the penalties of perjury, that the statements made by _________________________________________________________
of _________________________________________________________________________________________ are true, complete, and correct.
Date of enrollment (
)
Signature of manager of approved program sponsor
Date signed by manager (
)
(
)
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Parent category: Legal