Free 52334.FH11 - Indiana

APPLICATION FOR ELEVATOR CONTRACTOR LICENSE - INDIVIDUAL
State Form 52334 (R2 / 12-08) Approved by State Board of Accounts, 2008

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Attach additional pages as needed to complete this application. 1. APPLICANT INFORMATION
Name Name of organization Work address (number and street, city, state, and ZIP code) Title

DEPARTMENT OF HOMELAND SECURITY DIVISION OF FIRE & BUILDING SAFETY DIVISION OF ELEVATORS 402 West Washington Street, Room W246 Indianapolis, Indiana 46204 Telephone: (317) 232-2670 Fax: (317) 232-6609 www.in.gov/dhs/fire/branches/mechanical/elevators_amusement.html

E-mail address T elephone number

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2. PROOF OF ELIGIBILITY

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You, the applicant, must submit the following: Proof showing that you have at least five (5) years of documented Indiana work experience in the construction, maintenance, service, and repair of elevators. Documentation showing that you have successfully completed NAEC Certified Elevator Technician (CET) exam or NEIEP Elevator Mechanics exam. If you hold an elevator contractor license issued by another state, you may be eligible to obtain an Indiana Elevator Contractor License by reciprocity. Contact the Division of Elevators if you are licensed as an Elevator Contractor in another state. 3. PROOF OF INSURANCE You, the applicant, must submit the following (check applicable box): Certificate of Insurance that complies with the requirements of IC 22-15-5-14. Documentation showing that you are employed as an elevator contractor for the state of Indiana, an Indiana municipality, an Indiana county, or an Indiana educational institution (as defined by IC 20-12-0.5-1). 4. PROOF OF WORKERS COMPENSATION COVERAGE You, the applicant, must submit the following: Proof demonstrating that you are covered by workers compensation under IC 22-3-2-5. 5. CRIMINAL HISTORY Have you ever been charged or convicted of a crime other than a minor traffic violation? (check one) Yes No

If the answer to the above question is yes, you must submit the following information with the application: 1. Each address at which you have resided during the past five (5) years. 2. A current criminal history from every state in which you have resided during the past five years. In Indiana, and from every state in which you have been charged or convicted of a crime (other than a minor traffic violation). A limited criminal history can be obtained from the Indiana State Police (see http://www.in.gov/isp/lch/). 3. Certified copies of all charging instruments from any case in which you have been charged with a crime. This includes, but is not limited to, any probable cause affidavits. 4. Certified copies of any order regarding the final disposition from any in which you have been charged with a crime. This includes, but is not limited to, any plea agreements and sentencing orders. 5. If you were ever assessed any periods of probation, a letter detailing your satisfactory completion of all court-imposed requirements from all involved probation officers. 6. If you have ever been or are certified or licensed as an elevator professional in another state and that state has taken an action to revoke, suspend or otherwise limit your certification or license, include copies of all documents detailing the cause of the action and the final disposition of the action. 6. APPLICATION FEE You must include payment of the $500 license fee with this application. If paying by check or money order, make it payable to the Fire and Building Services Fund. If paying by Visa or MasterCard, complete the Credit Card Payment form on page 2. A check or money order for $500 is enclosed. Payment will be made by Visa or MasterCard. I have completed and enclosed the Credit Card Payment form. 7. AFFIRMATION I hereby affirm under penalty of perjury that all of the information provided with this application is true to the best of my knowledge.
Signature Date (month, day, year)

APPLICATION FOR ELEVATOR CONTRACTOR LICENSE - INDIVIDUAL (continued)
State Form 52334 (R2 / 12-08) Approved by State Board of Accounts, 2008

The application must include payment of the license fee of $500. If paying by Visa or MasterCard, complete the following information. CREDIT CARD PAYMENT
Full name on credit card Billing address (number and street, city, state, and ZIP code) Type of credit card (check one) Account number T elephone number

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Date of expiration (month, year)

Visa

MasterCard

CVV2 number (last three (3) digits of the number in the signature block on the back of the card)

By signing, Cardmember agrees to the obligations set forth by the Cardmembers Agreement with the issuer.
Signature Date (month, day, year)