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TEXAS STATE BOARD OF PLUMBING EXAMINERS

PO BOX 4200, AUSTIN, TEXAS, 78765 ▪ 512-936-5200 ▪

DRAIN CLEANER-RESTRICTED REGISTRATION APPLICATION

Revised October 2009

1. Date ___________ ►Incomplete applications expire one year from receipt. See instructions in #11, below.

2. Last name (Print) ___________________________________ First _______________________ MI _____

3. Mailing address ________________________________________ City __________________ State _____

4. Zip Code __________ Date of birth ______________________ Telephone No. ______________________

5. Plumber’s Apprentice Registration No. ____________

Please note that Apprentice Registration must be current.

6. Social Security No. _________________________ (Social Security No. will be verified) See Item # 7, below.

If you have been issued a Social Security Number, disclosure of your social security number is required. Your social security number is being solicited

pursuant to Texas Family Code Section 231.302 for use by the state’s Title IV-D agency to assist in the administration of laws relating to child support

enforcement under Parts A and D of Title IV of the Federal Social Security Act (42 U.S. C Sections 601-617 and 651-669).

7. If you have not yet been issued a Social Security Number by the Social Security Administration, you must

provide proof that you are a citizen or national of the United States, or an alien lawfully admitted to the United

States for permanent residence, or an alien authorized to work lawfully in the United States. Applicable proof

includes any of the following: (1) a certified copy of your birth certificate issued by a city/county/state/federal

certifying authority (if born in the United States); or (2) a certified copy of your Consular Report of Birth (if born

abroad to a U.S. citizen/parent); or (3) a legible copy of both sides of your Certificate of Naturalization or Certificate

of Citizenship (if a naturalized U.S. citizen); or (4) a legible copy of both sides of the U.S. Immigration and

Naturalization Service document evidencing your current status (if a permanent resident alien or an alien authorized

to work lawfully in the United States). Foreign birth certificates are not accepted.

8. Driver License or State Issued Identification Number _____________________________ State ________

9. Employer name _________________________________ Employer Phone Number __________________

Employer’s address _____________________________ City ___________________ St _____ Zip _____

Responsible Master Plumber______________________________ Master Plumber License No. _________

10. Have you ever been convicted of a felony in this state or any other state?

Yes

If you answer yes to this question, you must submit a Supplemental Criminal History

Information Form and all documentation listed on page 2 of the Form with this application. The Supplemental

Criminal History Information Form is available on the TSBPE website at

(Applications

and Forms).

11. Check the following boxes as you include the items which must be submitted with this application

in order for the application to be considered complete. Your application will not be processed unless

all items are submitted.

Application and non-refundable Fee of $18

(cashier’s check, money order, or personal or company check).

Drain Cleaner-Restricted Registrant Verification of Training Affidavit. This document is available on the

TSBPE website at .

Supplemental Criminal History Information Form and required documents (if you answered “yes” to #10).

12.

I UNDERSTAND THAT SUBMITTING ANY FALSE INFORMATION TO THE BOARD MAY RESULT IN

DISCIPLINARY ACTION, UP TO AND INCLUDING REVOCATION OF MY PLUMBING LICENSE OR

REGISTRATION AND AN ADMINISTRATIVE PENALTY NOT TO EXCEED $5,000.00.

___________________________________________

Signature of applicant

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

TSBPE USE ONLY

Fee ______________________________________

File No. ___________________________________

Drain Cleaner-Restricted Registration Application - Texas State Board Of Plumbing Examiners Page 2

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