Plumbers License Application - Vermont Department Of Public Safety Page 2
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5Vermont Department of Public Safety
OFFICE OF THE STATE FIRE MARSHAL, THE STATE FIRE ACADEMY AND THE STATE HAZ-MAT TEAM
PLUMBERS LICENSE APPLICATION
ALL CLASSIFICATIONS
We are required by the state of Vermont to have these forms filled out for our records each time you apply for a Commission, License or Certification. Be
aware that if the information that is requested is not filled out completely it could be returned to you and delay the process.
SECTION 1: APPLICATION TYPE AND FEES
Type S
$ 50.00 per field
(check category below)
Master
$120.00
P1 – Water Heater
P2 – Heating System
Journeyman
$90.00
P3 – Water Treatment
Initial Application
Reinstatement Request
Additional Testing Request
SECTION 2: APPLICANT INFORMATION
Full Legal Name: Last, First, Middle
Social Security Number:
Date of Birth:
Gender:
M
F
Mailing Address: Number/Street or P.O. Box
City
State
ZIP Code
Physical Address: Number/Street Only - NO P.O. Boxes
City
State
ZIP Code
Home Phone Number:
Cellular Phone Number:
Pager Number:
Electronic Mail Address (E-Mail):
Facsimile Number:
SECTION 3: EMPLOYMENT INFORMATION
Current
Contact Name and Phone Number:
Employer Name and Address:
Duties as employee:
Employment Dates( mm/yyyy-mm/yyyy):
Employer Name and Address:
Contact Name and Phone Number:
Duties as employee:
Employment Dates( mm/yyyy-mm/yyyy):
Employer Name and Address:
Contact Name and Phone Number:
Duties as employee:
Employment Dates( mm/yyyy-mm/yyyy):
Created on 9/7/2012
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