Form 2557 - Application For Or Renewal Of Registration As An Apprentice Plumber - Indiana Professional Licensing Agency
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1
2Indiana Professional Licensing Agency
APPLICATION FOR OR RENEWAL OF
302 W. Washington St., Rm. E034
REGISTRATION AS AN APPRENTICE PLUMBER
Indianapolis, IN 46204-2700
State Form 2557 (R8 / 2-99)
Telephone: (317) 232-2980
Approved by State Board of Accounts 1998
1. Please TYPE or PRINT and complete the application in it's entirety. Incomplete applications
INSTRUCTIONS:
will be returned.
FEE: $10.00
2. Enclose $10.00 fee, make check or money order payable to Indiana Professional Licensing Agency.
3. Attach a copy of "APPRENTICESHIP AGREEMENT" from the Bureau of Apprenticeship Training.
U.S. Department of Labor, or by certifying organization which is accepted by the Indiana Plumbing
Commission.
4. The plumbing contractor / journeyman plumber by whom you are employed must complete the
"EMPLOYER SECTION" of this application.
APPLICANT INFORMATION
Name of applicant
Application number
Date of birth
Address (number and street)
Telephone number
(
)
City, state, ZIP code
County
Social Security number *
* This agency is requesting the disclosure of your Social Security number in accordance with
IC 4-1-8-1. Disclosure is mandatory; this record cannot be processed without it.
APPLICANT NOTARY CERTIFICATE
I hereby certify that I am learning the plumbing trade, registered in an accredited plumbing training program and attaching a copy
of the "APPRENTICESHIP AGREEMENT " stating the school will timely inform the Commission of my termination from learning
the plumbing trade under the auspices of said school and/or the completion of the " PROGRAM CERTIFICATION " section. I fur-
ther certify that I cannot perform plumbing services without such services being performed under the direction and immediate
supervision of a licensed plumbing contractor or a licensed journeyman plumber physically present on the project.
Signature of applicant
Date (month, day, year)
STATE OF
}
SS:
COUNTY OF
Before me, a Notary Public, personally appeared __________________________________________________ who subscribed
and swore to the foregoing.
Name of applicant
Signature of Notary Public
Printed or typed name of Notary Public
Date subscribed and sworn to Notary Public
County of residence
Date commission expires
SCHOOL INFORMATION
Bureau of Apprenticeship training number
Name of Commission approved school
Program number
Method (check one)
Employer
Classroom
Shop
Source (check one)
Vocational education name: ____________________________________________________________________________
Sponsor name: ______________________________________________________________________________________
APPROVED APPRENTICESHIP PROGRAM SPONSOR CERTIFICATION
I hereby certify that _____________________________________________________ is successfully enrolled in four years of training in an approved
(name of apprentice)
apprenticeship program.
Date of enrollment (month, day, year)
Date signed by manager
Signature of manager of approved program sponsor
(Continued on reverse side)
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