Tdlr Form Oo4acr - Air Conditioning & Refrigeration Contractor Template (Page 4 of 4) in pdf

Tdlr Form Oo4acr - Air Conditioning & Refrigeration Contractor Template Page 4

TEXAS DEPARTMENT OF LICENSING AND REGULATION

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

· air.conditioning@license.state.tx.us

TEXAS AIR CONDITIONING CONTRACTORS LICENSE APPLICATION ATTACHMENT:

EXPERIENCE VERIFICATION FORM

This form should be completed by a person qualified to verify air conditioning and refrigeration

experience for the applicant. This form SHOULD NOT be completed by the applicant.

NAME OF APPLICANT:

SOCIAL SECURITY NUMBER _____________________________

NAME OF BUSINESS WHERE EXPERIENCE WAS ACQUIRED:

NAME OF PERSON VERIFYING EXPERIENCE:

TELEPHONE: (

)

[ ] YES [ ] NO

Are you a licensed Air Conditioning and Refrigeration Contractor?

If so, what is your license number

WAS APPLICANT: [ ] AN EMPLOYEE

[ ] A SUBCONTRACTOR

WHAT WAS OR IS YOUR RELATIONSHIP TO THE APPLICANT?

[ ]

Employer

[ ]

Supervisor

[ ]

Co-worker

[ ]

Other

FIRST DATE OF APPLICANT’S EMPLOYMENT:

LAST DATE OF APPLICANT’S EMPLOYMENT:

EMPLOYMENT OR SUBCONTRACTOR STATUS:

[ ] FULL TIME

[ ] PART TIME

______#OF HOURS WORKED EACH WEEK

DESCRIBE IN SPECIFIC DETAIL THE AIR CONDITIONING AND REFRIGERATION JOB DUTIES PERFORMED BY THE APPLICANT.

THE JOB DESCRIPTION MUST SPECIFY PRACTICAL EXPERIENCE WITH THE TOOLS OF THE TRADE:

BY SIGNING THIS FORM, I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.

Signature

Date

TDLR 034 ACR 12/10

Tdlr Form Oo4acr - Air Conditioning & Refrigeration Contractor Template Page 4