Plumbers License Application - Vermont Department Of Public Safety Page 3
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5SECTION 4: REFERENCES TO QUALIFICATIONS
Applicant will give the name and address of not fewer than three persons, unrelated to applicant, having knowledge of the applicant’s plumbing background.
Name:
Address:
Telephone:
1.
2.
3.
4.
SECTION 5: EDUCATION INFORMATION
Name and Location:
Dates Attended:
Diploma:
High School
YES
NO
College
YES
NO
Other (Specify)
YES
NO
YES
NO*
Apprenticeship
*(please explain)
SECTION 6: EXPERIENCE INFORMATION
If you currently hold a valid license in another state please attach a photocopy of each license.
If you have ever applied for a VT license before please indicate when: ________________________________
Time Served as an Apprentice:
Yrs.
Mos.
Time Served as a Journeyman:
Yrs.
Mos.
Time Served as a Master:
Yrs.
Mos.
Time Served as an Other (please specify):
Yrs.
Mos.
SECTION 7: AFFIDAVIT OF APPLICANT
I hereby certify that this application contains no willful misrepresentation or falsifications, and that the
information given by me is true and complete to the best of my ability.
Date:
Signature:
Printed Name:
Sworn and Subscribed before me this ____________ day of _________________________20______
______________________________________________ My Commission Expires________________
Notary Public Signature
State of ________________________________ County of ___________________________________
(*Notary seal required for oaths taken outside of Vermont*)
SECTION 8: CONTACT INFORMATION
Questions:
Licensing Specialist Nicole York @ (802) 479-7564 or Nicole.York@state.vt.us
Mail completed application and fees to:
Division of Fire Safety
Attn: Plumbers Licensing Board
1311 US RTE 302 – Suite 600 Berlin
Barre, VT 05676-2351
Created on 9/7/2012
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