Free 53522.FH11 - Indiana

APPLICATION FOR RECERTIFICATION BASED ON PREVIOUS CERTIFICATION
State Form 53522 (3-08) DEPARTMENT OF HOMELAND SECURITY

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INDIANA DEPARTMENT OF HOMELAND SECURITY Certification Supervisor 302 West Washington Street, Room E239 Indianapolis, Indiana 46204 Telephone: (800) 666-7784

INSTRUCTIONS:

1. 2. 3. 4.

This form is for individuals who want to reacquire a certification that was previously held by the individual. Please complete this form and return it to the above address. The applicant must complete the State written and practical skills examination tests. If the applicant fails either test, he/she must retake another training course.

Name of applicant (last, first, middle) Mailing address (number and street, city, state, and ZIP code) Identification number (drivers license number or state identification number) Previous certification number Date of issue (if known) (month, day, year)

Daytime telephone number

(

)

Date of birth (month, day, year) Date of expiration (month, day, year) Have you ever been charged or convicted of a crime other than minor traffic violations?

Please list any additional names you may have been certified under

Yes

No

Signature of applicant

Date (month, day, year)