Residential Appliance Installer License Application printable pdf download

TEXAS DEPARTMENT OF LICENSING AND REGULATION

PO Box 12157 · Austin, Texas 78711 · (800) 803-9202 · (512) 463-6599 · FAX (512) 475-2871

· electricians@license.state.tx.us

RESIDENTIAL APPLIANCE INSTALLER LICENSE APPLICATION INSTRUCTIONS

(Note: The instructions and application also apply to pool-related electrical maintenance technicians.)

This completed application is required prior to scheduling your Texas examination. If your ap-

plication is approved, we will contact the exam provider (PSI) and they will send you a postcard

to proceed with scheduling your Texas examination. The exam fee will be paid directly to PSI.

If you’ve passed the ICC exam prior to 09/01/09 and within two years of filing this application,

include a copy of the passing grade notice with your application.

GENERAL INSTRUCTIONS

The application must be completed and signed by the applicant. An application is not considered com-

plete and will not be processed until all items have been submitted as required. All information provided

must be typed or printed in black/blue ink. Attachments must be submitted on separate pieces of sin-

gle-sided, 8½” x 11” paper. Please use a paperclip (and not staples) to fasten all pages together, with

the check or money order for the exact amount on top. .

If one check will be used to pay for multiple applications, a Combined Check Worksheet must be

completed and submitted with the applications and payment. The Combined Check Worksheet is

available on the Department’s website.

GENERAL INFORMATION

NAME – Write your name in the spaces provided. (Last, First, Middle and Suffix) (MR is not a suffix.)

DATE OF BIRTH - Write the two digit numeric equivalent (ex: 03 for March) for the month of your

birth, followed by the two digit day and the four digit year. (MM/DD/YYYY)

GENDER – Indicate your gender.

SOCIAL SECURITY NUMBER Note 1 - The Social Security number disclosure is required by Sec-

tion 231.302(1) of the Texas Family Code in order to obtain a license. Your social security number is

subject to disclosure to an agency authorized to assist in the collection of child support pay-

ments. Failure to provide the SSN will prevent a license from being issued and could ultimately lead

to termination of the application. For more information regarding child support payments, contact the

Texas Attorney General at: or call (512)460-6000 or (800)252-

8014.

MAILING ADDRESS - This is the address to which the Department will mail your corre-

spondence, which includes postcards regarding your PSI exam information. Indicate the number

and street, or post office box of your mailing address.

PHYSICAL ADDRESS - This is the physical location of your residence. Do not use a post office box

for this address.

TELEPHONE NUMBER - Write the telephone number, including area code, where we can reach you

during the day. This may be your office phone number where we can leave a message.

FAX NUMBER – If you have access to a fax machine, write the fax number, including area code, where

the department can fax documents to you.

Residential Appliance Installer License Application