Plumbers License Application - Vermont Department Of Public Safety Page 5
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5Section 10: EMPLOYER AFFIDAVIT OF EXPERIENCE
This page may be reproduced if additional employment verification is necessary.
Full Legal Name: Last, First, Middle
Date of Birth:
Telephone Number:
Mailing Address: Number/Street or P.O. Box
City
State
ZIP Code
~Shaded area below MUST be completed by the certifier in its entirety~
I, ________________________, hereby subscribe to and vouch for the statement made by
__________________________ (applicant) on their application for consideration for the marked
request. I have employed/supervised/worked alongside the named applicant in the capacity of
___________________________________for a total accumulated time of _________________hours.
IN THE SPACE BELOW, LIST ALL SPECIFIC TRADE DUTIES (generalizations will not be accepted) APPLICANT PERFORMED OR
SUPERVISED IN THE CLASSIFICATION FOR WHICH HE/SHE IS APPLYING.
**I understand that providing false information to the Plumbers’ Examining Board about the information provided herein is grounds for
disciplinary action against my license. I may be asked to appear before the board and explain my work involvement with the applicant.**
Date:
Signature:
Printed Name:
My relationship to applicant is:
Employer
Fellow Employee
Foreman or Supervisor
Business Associate
Union Representative
Client ( if applicant is self- employed)
Other:____________________________
Company Name:
License Number:
Position:
Phone Number:
Facsimile Number:
Electronic Mail Address:
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*)
Created on 9/7/2012
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