Application for Apprentice Plumber’s License
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State of Illinois
Illinois Department of Public Health
Printed by Authority of the State of Illinois
IOCI 15-473
Application Continued on Opposite Side
*OFFICIAL USE ONLY*
056 __ __ __ __ __ __
____________________
Date First Licensed
I graduated from ______________________________________________________________ in _____________.
(Name of High School) (Year Graduated)
- OR -
I completed ______ years of high school at _________________________________________________________.
(Name of High School)
___________________________________________________________________________________________________
Complete Address of High School
I am employed by Mailing Address
City State ZIP Code County
Business Phone Plumbing Contractor Registration Number
055-
I have read the State of Illinois Plumbing License Law and understand my responsibilities as a licensed apprentice plumber.
I understand that no person shall work as an apprentice plumber unless he is employed by a person authorized to contract or
work as a plumber and such apprentice is licensed in accordance with the State of Illinois Plumbing License Law. I will
immediately notify the Illinois Department of Public Health of any change of information that is a part of this application.
CHILD SUPPORT CERTIFICATION
By law, (51ILCS 100/10-65 (C)), all applicants, regardless of whether they have children or not, must certify whether they are
or are not delinquent in the payment of child support. Check one statement below:
__ Does not apply to me.
__ I am more than 30 days delinquent in complying with a child support order.
__ I am in compliance with a child support order.
I understand if I refuse to complete this certification or if I provide false/fraudulent information, I could lose my license, be fined
or have other penalties assessed. Therefore, I declare that I have examined this form and, to the best of my knowledge, all
statements are true, correct and complete.
_______________________________________________________ ________________________
Applicant Signature Date
Important Notice
This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Illinois Plumbing License
Law, 225 ILCS 320. Disclosure of this information is mandatory. Failure to provide any information could result in denial of the contractor license. This form
has been approved by the Forms Management Center.
Last Name First Name Middle Name
Home Street Address City
State ZIP Code County
Work Phone Home Phone
Date of Birth Height Weight
Ft. In. lbs.
Social Security Number Gender
❑ Male ❑ Female
