Medical Gas Piping Installation Endorsement Examination Application - Texas State Board Of Plumbing Examiners Page 2

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TEXAS STATE BOARD OF PLUMBING EXAMINERS
P O BOX 4200, AUSTIN TEXAS, 78765 ▪ 512-936-5200 ▪
MEDICAL GAS PIPING INSTALLATION ENDORSEMENT EXAMINATION APPLICATION
DATE _________________ Incomplete applications expire one year from receipt. See instructions below.
1. Last name (Print) ____________________
___ First ____________________
MI__________
2. Mailing address __________________________ City ____________________________ State ________
3. Zip Code _________
Date of birth _____________________
Telephone No. ____________________
4. Employed by __________
_________________
Employer Phone No. ____________________
5. Driver’s License/ID No. ____
___________________ Social Security No. ______
_________________
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).
6. Please indicate which Medical Gas Piping Endorsement examination you are applying for. License must
be current in order to apply for the endorsement.
Master (fee $80) Master Plumber License # _________________ Expiration date _________________
Journeyman (fee $27) Journeyman Plumber License # _______________ Expiration date __________
Inspector (fee $40) Plumbing Inspector License # __________________ Expiration date ____________
7. Have you ever been convicted of a felony?
Yes
or No
If your answer yes to this question, you must submit a Supplemental Criminal History Form and all
documentation listed on page 2 of the Supplemental Criminal History Information Form with this application. The
Supplemental Criminal History Form is available on the TSBPE website at
(under Applications and
Forms) or by calling our office at 512-936-5200.
The following items must be submitted with this application in order for it to be processed:
 Application and Examination Fee $80/Master, $27/Journeyman, or $40/Inspector (cashier’s check, money order
or personal or company check)
 Certification of completion for Board-approved training certification program
 Supplemental Criminal History Information Form and required documents (if you answered “yes” to #7)
I UNDERSTAND THAT SUBMITTING 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
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
OFFICE USE ONLY
Fee _________________________
File No._______________________
1. SCHED:_______________[____]
2.SCHED:______________[____] 3. SCHED: _____________[_____]
Revised January 2015

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