Free 53175.FH11 - Indiana

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APPLICATION FOR LICENSURE AS A HOME INSPECTOR
State Form 53175 (7-07) Approved by State Board of Accounts, 2007

HOME INSPECTORS LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, IN 46204 Telephone: (317) 234-3009 E-mail: [email protected] www.pla.IN.gov

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER ISSUED DATE LICENSE ISSUED (month, day, year) LICENSE OBTAINED BY Please attach one (1) passport type quality photograph here. (See Instructions)

* Your Social Security Number is being requested by this state agency in accordance with Indiana Code § 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it. Social Security Numbers are available to the Indiana Department of Revenue.
DO NOT WRITE ABOVE THIS LINE ALL INFORMATION ON THIS FORM MUST BE TYPED OR CLEARLY PRINTED. APPLICANT INFORMATION
Name (last, first, middle, maiden or previous)

Current address (number and street or rural route)

City

State

ZIP code

Permanent address, if different from the above current address (number and street or rural route)

City

State

ZIP code

Work telephone number

Home telephone number

E-mail address

(

)

(

)
Social Security number

Date of birth (month, day, year)

Place of birth (city and state)

*

EDUCATION INFORMATION

Have you graduated from high school or obtained a GED?
Name of school Location (city and state)

Yes

No

If Yes, please provide information below.
Diploma / GED date (month, day, year)

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PRE-LICENSING COURSE INFORMATION

Have you completed a Board-approved pre-licensing course?

Yes

No

If Yes, please provide information below.

APPLICANTS MUST ATTACH AN ORIGINAL OR NOTARIZED COPY OF THEIR CERTIFICATE OF COURSE COMPLETION. (If you are applying for licensure via reciprocity or under the grandparenting provision, then you are not required to submit this certificate or complete this section.
Name of course provider Indiana Course Provider Registration number Date of completion (month, day, year)

Location (city and state)

Number of classroom credit hours completed

Number of in-field training hours completed

CERTIFICATE OF INSURANCE (Applicants must attach an original or notarized copy of their Certificate of Insurance)
Name of insurance provider

Telephone number of insurance provider

Policy number

(

)
OTHER STATE LICENSURE / CERTIFICATION / REGISTRATION / PERMIT

Do you now hold, or have you ever held, a license / certificate / registration / permit to practice or perform any regulated profession by a state licensing board? Yes No If Yes, list all states below, including Indiana, in which you have held license / certification / registration / permit to practice any state regulated profession. STATE LICENSE NUMBER DATE ISSUED (month, day, year) STATUS

TYPE OF LICENSE / CERTIFICATE / REGISTRATION / PERMIT

If your answer is Yes to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date, and disposition. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any license, registration, certificate, or permit that you hold or have held? 2. Have you ever been denied a license, registration, certificate, or permit to practice or perform any regulated occupation in any state (including Indiana) or country? 3. Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 4. Are you currently, or have you ever been, listed on a national or state registry of sex offenders? Yes Yes Yes Yes No No No No

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APPLICATION AFFIRMATION

I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, or the Indiana Home Inspectors Licensing Board, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board, or any of their authorized representatives, in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency and the Indiana Home Inspectors Licensing Board, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information, which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.
AFFIRMATION

I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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