Free 53858.FH11 - Indiana

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APPLICATION FOR LICENSURE AS A MANUFACTURED HOME INSTALLER
State Form 53858 (3-09) Approved by State Board of Accounts, 2009

INSTRUCTIONS:

All information must be typed or clearly printed.

MANUFACTURED HOME INSTALLERS LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

* Your Social Security number is being requested by this state agency in accordance with IC 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.

FOR OFFICE USE ONLY 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 quality photograph here.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name (last, first, middle, maiden or previous) Address (number and street or rural route, city, state, and ZIP code) Date of birth (month, day, year) Residential telephone number Place of birth E-mail address Social Security number *

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PRE-LICENSING COURSE INFORMATION Applicants must attach an original or notarized copy of their certificate of course completion.
Have you completed a Board-approved pre-licensing course?

Yes
Name of Board-approved course provider Location (city and state)

No

If yes, please provide the information below.
Date course completed (month, day, year) Indiana course provider registration number

INSURANCE / SURETY BOND INFORMATION Applicants must attach an original or notarized copy of their certificate of insurance.
Name of insurance / surety bond company Telephone number of insurance / surety bond company Amount of coverage Policy number Dates of coverage (month, day, year)

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From

To

SUPERVISED EXPERIENCE INFORMATION Please list all places of employment involving home installation which verify one (1) year of supervised experience. In addition to completing this section, applicants must also have each listed supervisor complete the Verification of Supervised Experience page in order to verify experience. NOTE: This section does not need to be completed if utilizing the professional references option.
Name of current employer Name of former employer Name of former employer Name of former employer Name of supervisor Name of supervisor Name of supervisor Name of supervisor Dates of employment (month, day, year) Dates of employment (month, day, year) Dates of employment (month, day, year) Dates of employment (month, day, year)

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PROFESSIONAL REFERENCE INFORMATION Please list three (3) professional references that are not related to you. Two (2) of these professional references must be licensed manufactured home installers who are familiar with your work experience and professional competency. In addition to completing this section, applicants must also have each individual professional reference complete the Professional Reference page in order to verify experience. NOTE: This section does not need to be completed if utilizing the supervised experience option. FULL NAME MANUFACTURED HOME INSTALLER LICENSE 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. TYPE OF LICENSE / CERTIFICATE / REGISTRATION / PERMIT STATE LICENSE NUMBER DATE ISSUED STATUS

CRIMINAL HISTORY & LICENSE DISCIPLINARY INFORMATION 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 professional license, certificate, registration or permit you hold or have held? 2. Have you ever been denied a license, certificate, registration 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? 5. Are you currently or have you ever been, treated for controlled substance abuse or alcohol abuse? APPLICANT 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)

Yes Yes Yes Yes Yes

No No No No No

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 Manufactured Home Installers Licensing Board, any files, documents, records or other information pertaining to the undersigned, requested by the Agency, the Board or any of its 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 or the Manufactured Home Installers 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)

CERTIFICATION OF NOTARY PUBLIC STATE OF ______________________________________ SS: COUNTY OF _______________________________

SEAL

I, ________________________________________________, being duly sworn on oath, say that I am the above named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant Signature of notary public Printed name of applicant Printed name of notary public County of residence Date subscribed and sworn (month, day, year) Date commission expires (month, day, year)

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VERIFICATION OF SUPERVISED EXPERIENCE
Part of State Form 53858 (3-09)

INSTRUCTIONS:

All information must be typed or clearly printed.

MANUFACTURED HOME INSTALLERS LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

APPLICANT INFORMATION The applicant should complete this section, then submit this page to his/her licensed supervisor for further completion. If more than one (1) licensed supervisor was used to obtain the one (1) year of required experience, then the applicant must make a copy of this page for each licensed supervisor.
Name of applicant Social Security number * Name of business (employer) Address of business (number and street or rural route, city, state, and ZIP code) Name of supervisor Title of supervisor Date of birth (month, day, year) Residential telephone number

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I hereby authorize the above named supervisor to furnish the Indiana Professional Licensing Agency with the information below.
Signature of applicant Date (month, day, year)

SUPERVISOR INFORMATION The applicants licensed supervisor should complete this section. Upon completion, please have this page notarized and submit the page directly to the Professional Licensing Agency at the above address.
Name of business (employer) Name of supervisor Type of employment If part time, annual hours worked Title of supervisor Dates of employment (month, day, year) Position held License number of supervisor

Full time
Quality of work

Part time Very good Average Fair

From

To Below average Poor

Excellent

Briefly summarize the work performed by the applicant.

CERTIFICATION OF NOTARY PUBLIC STATE OF ______________________________________ COUNTY OF _______________________________ SS: SEAL

I, ________________________________________________, being duly sworn on oath, say that I am the above named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of supervisor Signature of notary public Printed name of supervisor Printed name of notary public County of residence Date subscribed and sworn (month, day, year) Date commission expires (month, day, year)

PROFESSIONAL REFERENCE
Part of State Form 53858 (3-09)

INSTRUCTIONS:

All information must be typed or clearly printed. APPLICANT INFORMATION

MANUFACTURED HOME INSTALLERS LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

The applicant should complete this section, then submit this page to the individual who is providing a professional reference for further completion. The applicant must make a copy of this page for each individual professional reference.
Name of applicant Social Security number * Date of birth (month, day, year) Residential telephone number

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I hereby authorize the following professional reference to furnish the Indiana Professional Licensing Agency with the information below.
Signature of applicant Date (month, day, year)

PROFESSIONAL REFERENCE INFORMATION The individual who is providing a professional reference should complete this section. Upon completion, please have this page notarized and submit the page directly to the Professional Licensing Agency at the above address.
Name of individual providing professional reference Address of individual providing professional reference (number and street or rural route, city, state, and ZIP code) Telephone number of individual providing professional reference E-mail address of individual providing professional reference License number (if applicable)

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Please indicate, to the best of your knowledge, the applicants ability to perform manufactured home installation by checking the appropriate boxes. If you select Unsatisfactory for either technical competence or professional conduct, please submit a letter of explanation with this Professional Reference. NOTE: If you are not a licensed manufactured home installer, you do not need to complete this section.
Technical competence

Excellent
Professional conduct

Satisfactory Satisfactory

Marginal Marginal

Unsatisfactory Unsatisfactory

Not qualified to answer Not qualified to answer

Excellent

Please provide any additional details regarding the applicants professional abilities. If you need additional space, please provide a letter with this Professional Reference.

CERTIFICATION OF NOTARY PUBLIC STATE OF ______________________________________ COUNTY OF _______________________________ SS: SEAL

I, ________________________________________________, being duly sworn on oath, say that I am the above named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of individual providing professional reference Signature of notary public Printed name of individual providing professional reference County of residence Date subscribed and sworn (month, day, year) Date commission expires (month, day, year)

Printed name of notary public