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APPLICATION FOR CORPORATE PLUMBING CONTRACTOR LICENSE
State Form 11812 (R8 / 3-09) Approved by State Board of Accounts, 2009

INDIANA PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3022 E-mail: [email protected]

INSTRUCTIONS: Please print or type.

FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE OF ISSUE (month, day, year)

DO NOT WRITE ABOVE THIS LINE

* Federal ID number is requested by this agency in accordance with IC 4-1-8-1, and is mandatory that it be given. Federal ID numbers are available to the Indiana Department of Revenue.
Name of corporation Address (number and street, city, state, and ZIP code) County State of incorporation Telephone number ( ) E-mail address Federal Identification number *

If not Indiana, supply the date when admitted to do business Date of incorporation or admission (month, day, year) as foreign corporation in Indiana (month, day, year) Name of designated licensed plumbing contractor (corporate officer or employee) Title of designated licensed contractor, if corporate officer Address (number and street, city, state, and ZIP code) County Indiana plumbing contractor license number Telephone number ( )

NAMES

CORPORATE OFFICERS ADDRESSES (number and street, city, state, and ZIP code)

CERTIFICATION STATEMENT We hereby certify the above information is true and correct, and that the designated plumbing contractor and officers of the plumbing corporation making this application have not been convicted of an act which would constitute a ground for disciplinary sanction under Indiana Code 25-28.5-1-27.1, nor of a felony that has a direct bearing on the corporations ability to practice plumbing competently. We further certify, that ______________________________________________(designated plumbing contractor) has authority from the said corporation to transact business pursuant to the license applied for herein, and agrees to be responsible for the corporations use of said license in accordance with Indiana Code 25-28.5-1, which shall terminate only upon written notice to the Indiana Plumbing Commission, upon resignation, or removal from official status in the corporation as above described.
Signature of designated plumbing contractor Signature of corporate officer Printed name of designated plumbing contractor Printed name and title of corporate officer (See back of application) Date signed (month, day, year) Date signed (month, day, year)

NOTARY CERTIFICATE (SWORN OATH - DESIGNATED PLUMBING CONTRACTOR)

STATE OF _________________________________________ COUNTY OF _______________________________________

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SS:

I, ____________________________________________________________________________, having been duly sworn on oath, say that I am the above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of designated plumbing contractor Printed or typed name of designated plumbing contractor Date subscribed and sworn to Notary Public (month,day, year) Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires (month,day, year)

NOTARY CERTIFICATE (SWORN OATH - CORPORATE OFFICER)

STATE OF _________________________________________ COUNTY OF _______________________________________

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SS:

I, ____________________________________________________________________________, having been duly sworn on oath, say that I am the above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of corporate officer Printed or typed name and title of corporate officer Date subscribed and sworn to Notary Public (month,day, year) Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires (month,day, year)