Free 44861.pdf - Indiana

NOTIFICATION OF DESIGNATED LICENSED PLUMBING CONTRACTOR FOR LICENSED CORPORATE PLUMBING CONTRACTOR
State Form 44861 (R / 9-94) Approved by the State Board of Accounts 1991

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INDIANA PROFESSIONAL LICENSING AGENCY INDIANA PLUMBING COMMISSION 302 WEST WASHINGTON STREET, ROOM E034 INDIANAPOLIS IN 46204-2700 (317) 232-2980 License number

Name of corporate plumbing contractor Address (street and number) City County Name of designated individual Address (street and number) County Name of designated individual Address (street and number) County City Indiana Plumbing Contractor License Number City Indiana Plumbing Contractor License Number State

ZIP code Telephone number

( Title of designated individual State

)

ZIP code

Telephone number ( Title of designated individual State Telephone number ( ) )

ZIP code

CERTIFICATION STATEMENT

I hereby certify that the above information is true and correct, and that the Corporation making this certification has 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 Corporation's ability to practice plumbing competently. I further certify, that I have authority from the said Corporation to transact business pursuant to the license issued and that I agree to be responsible for the Corporation's use of said license, in accordance with Indiana Code 25-28.5-1, which shall terminate only upon my written notice to the Indiana Plumbing Commission even if I have resigned or been removed from my official status in the Corporation as above described.
Signature of designated individual Signature of designated individual Date signed (month, day, year) Date signed (month, day, year)

NOTARY CERTIFICATE

STATE OF

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COUNTY OF Before me, a notary public, personally appeared and swore to the foregoing.

SS:

who subscribed

Signature of individual Printed or typed name of individual Date subscribed and sworn to (Notary Public)

Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires