Free 53617.FH11 - Indiana

APPLICATION FOR MANUFACTURED HOME INSTALLER LICENSING / CONTINUING EDUCATION COURSE PROVIDER
State Form 53617 (6-08)

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

INSTRUCTIONS:

1. A completed application includes the following: a. A completed and notarized application. b. A descriptive course outline for each course. c. A professional biography for each instructor. d. A sample course completion certificate. e. A course evaluation form. 2. A separate application must be submitted for each course provider.
Name of course provider

Reset Form

Type of course provider

Licensing course provider

Continuing Education course provider

Address of course provider (number and street, city, state, and ZIP code) Name of contact person Type of ownership (check one) Telephone number E-mail address

(

)

Partnership

LLC / LLP

Corporation

If the ownership of the course provider is a partnership, LLC / LLP, or corporation, provide ownership information below.
Title

Name of partner / manager / director / officer Address (number and street, city, state, and ZIP code) Name of partner / manager / director / officer Address (number and street, city, state, and ZIP code) Name of partner / manager / director / officer Address (number and street, city, state, and ZIP code) Name of partner / manager / director / officer Address (number and street, city, state, and ZIP code)

Title

Title

Title

TITLE OF COURSE

LIST OF COURSES HOURS

NAME OF INSTRUCTOR

Page 1 of 2

Have you read and understand the statutes and rules regarding course requirements found in 879 IAC 1-4 through 879 IAC 1-8?

Yes

No

STATE OF INDIANA SS COUNTY OF ________________ I (We), the undersigned, submit this application in conformance with 879 IAC 1-6-1 pertaining to manufactured home installer licensing / continuing education course provider approval. I (We) understand that any violation of the license law or rules on my (our) part will subject me (us) to loss of approval. I (We) certify that the information given in this application is true and correct to the best of my (our) knowledge.
Signature of principal officer, partner, manager, or sole proprietor Date subscribed and sworn to Notary Public (month, day, year)

Printed name of principal officer, partner, manager, or sole proprietor

Signature of Notary Public

Printed name of Notary Public

County of residence

My commission expires (month, day, year)

FOR OFFICE USE ONLY Approved Tabled Reason:

Denied

Reason: