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APPLICATION FOR JOURNEYMAN PLUMBER OR PLUMBING CONTRACTOR EXAMINATION FOR LICENSING
State Form 40602 (R11 / 4-09) Approved by State Board of Accounts, 2009

PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204-2298 Telephone: (317) 234-3022 E-mail: [email protected] www.in.gov/pla

INSTRUCTIONS:

1. Please print clearly in ink. 2. All fees are non-refundable and non-transferable.

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1; it is mandatory that it be given. Social Security numbers are made available to the Department of Revenue.

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 Check only one: Journeyman plumber APPLICANT INFORMATION
Name (last, first, middle, maiden) Address (number and street) City, state, and ZIP code Date of birth (month, day, year) Telephone number Place of birth E-mail address Social Security number *

Plumbing contractor

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INDIANA RESIDENTS I have successfully completed the following four (4) years of training and successfully passed a practical examination in an approved apprenticeship program satisfying the requirements as defined in commission rule 860 IAC 1-1-9 and 860 IAC 2-1-7.1.
Name of apprenticeship program sponsor Address (number and street, city, state, ZIP code, and county) Telephone number

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Date of enrollment (month, year)

Date of completion (month, year)

APPROVED APPRENTICESHIP PROGRAM SPONSOR CERTIFICATION OF COMPLETION I hereby certify that _______________________________________________________________________________________________ successfully
Name of apprentice

completed (4) years of training and successfully passed a practical examination in an approved apprenticeship program, per 860 IAC 1-1-9 and 860 IAC 2-1-7.1.
Date of enrollment (month, year) Date of completion (month, year) Signature of manager of approved apprenticeship program sponsor Date signed (month, day, year) Page 1 of 2

FOR OUT-OF-STATE AND INDIANA LICENSED JOURNEYMEN PLUMBERS APPLICANTS ONLY
I have completed the following four (4) years of experience in the plumbing trade, satisfying the requirements as defined in commission rule, 860 IAC 1-1-9 and 860 IAC 1-1-10, as verified by employer, attached herewith:
Name of employer Address (number and street, city, state, and ZIP code) County Name of employer Address (number and street, city, state, and ZIP code) County Telephone number Dates of employment (month, day, year) Telephone number Dates of employment (month, day, year) Plumbing contractor license number (if applicable): PC

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PC

From

To

Plumbing contractor license number (if applicable):

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To

EMPLOYER AFFIDAVIT OF EXPERIENCE IN PLUMBING TRADE I hereby certify that ____________________________________________________________ has worked in the plumbing trade as
Name of applicant

defined in commission rule 860 IAC 1-1-10 for the period of ___________________________ to ___________________________.
Month, day, year Month, day, year

Signature of employer or licensed plumbing contractor Address (number and street, city, state, and ZIP code)

Name of company or plumbing business

Plumbing contractor license number Date signed (month, day, year)

Licensees who submit false information may be subject to disciplinary action by the Indiana Plumbing Commission.

NOTARY CERTIFICATE
STATE OF COUNTY OF

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I, , having been duly sworn on oath, say that I am the above-named, that I have personally prepared the foregoing affidavit, and that the same is true to the best of my knowledge and belief.
Signature of employer Printed or typed name of employer 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)

PERSONAL BACKGROUND
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 or insurance companies are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a permit issued pursuant to this application. 1. 2. 3. 4. Has disciplinary action ever been taken regarding any license, certificate, registration or permit you hold or have held? Have you ever been denied a license, certificate, registration or permit in any state (including Indiana)? Are you now being, or have you ever been treated for drug or alcohol abuse? Have you ever been convicted of, plead guilty or nolo contendere to any offense, misdemeanor or felony in any state? Yes Yes Yes Yes No No No No

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 any files, documents, records, or other information pertaining to the undersigned requested by the Agency, or any of their authorized representatives in connection with processing my application for registration to practice Plumbing. 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. A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Signature of applicant Page 2 of 2 Date signed (month, day, year)