Form 08-4182g - Verification Of Work Experience For Certification As An Underground Storage Tank Worker

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STATE OF ALASKA
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
333 WILLOUGHBY AVENUE, 9TH FLOOR
P.O. BOX 110806
JUNEAU, ALASKA 99811-0806
(907) 465-5470
E-mail: license@dced.state.ak.us
VERIFICATION OF WORK EXPERIENCE FOR CERTIFICATION
AS AN UNDERGROUND STORAGE TANK WORKER
THIS FORM TO BE COMPLETED ONLY IF APPLYING BY RECIPROCITY.
PART I. (Please PRINT)
APPLICANT: Complete Part I. Then forward to the state in which you were examined and certified for completion
of Parts II and III below. This form is to be sent directly from the licensing agency to this division. All costs
associated with compliance of this request should be prepaid by you.
Name:
Last
First
MI
Maiden
Address:
Street
City
State
Zip Code
Telephone Number:
Social Security Number:
Signature
Date
THE INFORMATION BELOW MUST BE COMPLETED BY THE APPROPRIATE STATE LICENSING AGENCY.
IT IS NOT TO BE COMPLETED BY THE APPLICANT.
PLEASE DO NOT DETACH
PART II.
The above-named applicant is applying for certification as an underground storage tank worker in the State
of Alaska. Please complete the following and return to the Division of Occupational Licensing at the
address listed above.
Social Security Number:
Date of Birth:
Date Certificate Issued:
Certificate Number:
Name of Title of License:
Basis of Certificate:
Exam (Date:
)
Credentials
Other, please specify:
Status:
Current
Inactive
Lapsed
Expiration Date:
Has this certificate ever been the subject of any licensing action?
Yes
No
Date:
If yes, please explain:
08-4182g (Rev. 1/00)
CONTINUED ON REVERSE SIDE

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