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Request For Duplicate License/registration Card Or License Certificate - Texas State Board Of Plumbing Examiners

TEXAS STATE BOARD OF PLUMBING EXAMINERS

PO Box 4200 • Austin, Texas 78765-4200

(800) 845-6584 • (512) 936-5200

REQUEST FOR DUPLICATE LICENSE/REGISTRATION CARD OR LICENSE CERTIFICATE

Please note: Only the licensee or registrant may request a duplicate license card or certificate. This

completed form must be returned with payment of $10.00. Please allow 7-10 days for processing.

Request for

Duplicate Pocket Card

Duplicate Paper Wall Certificate

Last name: ________________________ First name: ___________________ MI ____________

License or registration number ______________________

DOB: _____________________

Address ___________________________________ City ____________________ St. _________

Zip ________ Daytime Ph. # ___________________ DL or State issued ID# ________________

What happened to original card or certificate issued?___________________________________

I understand that submitting any false information to the Board may result in disciplinary action, up to

and including revocation of my license or registration and an administrative penalty not to exceed

$5,000. I understand that the penalties for perjury or tampering with a governmental record through

false entry of information may consist of (1) a fine not to exceed $4,000. (2) confinement in jail for a

term not to exceed one year; or (3) both such fine and confinement. By signing this form, I hereby

affirm that all of the facts, statements, and answers contained herein are true.

Signature of licensee or registrant making request _____________________________________

Date: _____________________________________

Before me, the undersigned authority, personally appeared _____________________________,

who has identified themselves through a drivers license or state issued photo ID.

SWORN TO AND SUBSCRIBED before me, the undersigned authority, on this the ___________

day of _______________________, ___________.

_____________________________________

SEAL

Notary Public in and for the State of Texas

________________________________________________________________________________

Office use only

Fee type/amount ___________________ Date rec’d ________________ Initials ________

File # ________________

Date processed: _______________________

Revised October 2009

Request For Duplicate License/registration Card Or License Certificate - Texas State Board Of Plumbing Examiners