Fillable Application to Take the Examination to Become a (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

Fill Online, Printable, Fillable, Blank Application to Take the Examination to Become a (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) Form

Use Fill to complete blank online STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application to Take the Examination to Become a (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

On average this form takes 87 minutes to complete

The Application to Take the Examination to Become a (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General) form is 20 pages long and contains:

  • 6 signatures
  • 86 check-boxes
  • 284 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

BROWSE STATE OF NEW JERSEY, DEPT. OF LAW & PUB. SAFETY, OFFICE OF THE ATTORNEY GENERAL (NJ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
New Jersey Ofce of Attorney General
Division of Consumer Affairs
State Board of Examiners of Master Plumbers
124 Halsey Street, 6th Floor, P.O. Box 45008
Newark, New Jersey 07101
(973) 504-6420
Application to Take the Examination to Become a Licensed Master Plumber
(Instruction Sheet)
(Pursuant to N.J.S.A. 45:14C-15)
GENERAL INSTRUCTIONS: Applications must be neatly typewritten or printed and signed. Include two (2) signed, full-
face passport-style photographs (2” x 2”). All sections of the application must be fully completed before the application can be
processed. If any section of the application is not of sufcient size to furnish the required information, a supplemental sheet of
paper of the same size may be enclosed with the application.
13:32-2.1 ELIGIBILITY FOR EXAMINATIONS
a) To be eligible to take the plumbing license examination an applicant shall:
1) Be 21 years of age or older; and
2) Have completed the experience requirements set forth in N.J.A.C. 13:32-2.2 below.
b) An applicant for the plumbing licensing examination shall submit to the Board:
1) A completed application for examination including a full street name and number. An application containing only
a post ofce box number as a mailing address shall not be considered a complete application;
2) Proof that the applicant has met the experience requirements set forth in N.J.A.C. 13:32-2.2; and
3) The application fee as set forth in N.J.A.C. 13:32-5.1.
c) After a review of the information required in (b) above, the Board shall send a letter that informs the applicant
whether he or she is eligible to take the licensing examination required by N.J.A.C. 13:32-2.3 and, if deemed eligible,
advises of the time and place of examination.
13:32-2.2 EXPERIENCE REQUIREMENTS
a) For purposes of this section, “practical hands-on experience” means experience in the installation, maintenance, extension,
alteration, repair and removal of piping, plumbing xtures, plumbing appliances and plumbing apparatus. Practical hands-on
experience does not include time spent in performing managerial tasks, such as supervising, engineering, estimating, or time
spent performing tasks which do not constitute the practice of plumbing as dened in N.J.A.C. 13:32-1.3.
b) An applicant for examination for a license as a master plumber shall present proof to the Board that he or she:
1) Has completed a four-year apprenticeship program approved by the United States Department of Labor and has completed
one year of practical hands-on experience as a journeyman plumber; or
2) Has been awarded a bachelor’s degree in mechanical, plumbing or sanitary engineering from a college or university
accredited by a regional accreditation agency recognized by the Council on Post-Secondary Accreditation or the United
States Department of Education, and has completed one year of practical hands-on experience as a journeyman plumber.
Please note: The Board requests W-2s from applicants as evidence of employment in meeting these qualications for the years
while enrolled in apprenticeship training and the one (1) additional journeyman year.
Also note that according to existing New Jersey Plumbing Statutes and Regulations, the “Journeyman” year is gained under the
supervision of a Licensed Master Plumber, which by denition, is licensed in the State of New Jersey.
13:32-1.3 DEFINITIONS
“Journeyman plumber” means an individual who has completed four years engaged in learning and assisting in the installation
of plumbing and who works under the supervision of a master plumber or supervisory journeyman plumber.
“Licensed master plumber” means a person licensed pursuant to N.J.S.A. 45:14C-1 et seq. who has the qualications, training,
experience and technical knowledge necessary to properly plan, lay out, install and repair plumbing apparatus and equipment and
to supervise others in the performance of such work in accordance with the rules established in this chapter.
13:32-2.3 EXAMINATIONS
a) Examinations shall be prepared and administered by PSI SERVICES, LLC., or its successor, but no license shall be granted
except by the Board. The Board chairman may designate members of the Board to oversee the administration of the
examination.
b) Examinations shall be held at least four times annually and at such additional times as the Board may determine.
c) Examinations shall consist of three parts:
1) A written examination based on the National Standard Plumbing Code as adopted by the State of New Jersey pursuant to
the Uniform Construction Code Act, N.J.S.A. 52:27D-119 et seq.;
2) A practical examination; and
3) A written examination covering the laws and regulations governing the occupation and business of plumbing.
d) In order to pass the examination, an applicant must receive a minimum grade of 70 in each of the three areas outlined in (c)
above.
13:32-2.4 FAILURE OF EXAMINATION - WHEN RETAKING IS PERMITTED
a) An applicant who has failed the plumbing licensing examination may review his or her examination upon written request to
PSI SERVICES, LLC., or its successors, and payment to the testing service of its review fee.
b) No person who has failed the examination shall be eligible to be re-examined for a period of six months from the date of the
examination led by such person.
DOCUMENTING YOUR WORK EXPERIENCE: A Work Experience Certication form is attached and may be reproduced.
The applicant must have the form(s) completed by his/her employer(s) to verify employment in the plumbing trade for the years
enrolled in formal apprenticeship training, and during the one (1) year of practical hands-on experience as a journeyman plumber.
CRIMINAL HISTORY BACKGROUND: Be sure to answer questions number 9 through 18 on the application regarding any
convictions you may have had in the past; detail the conviction(s) and provide all of the supporting documentation regarding
same such as judgment(s) of conviction, any court documents regarding the details of the conviction and the nal disposition of
each matter. Prepare and attach a notarized statement in your own words explaining the circumstances surrounding each offense.
CHILD-SUPPORT QUESTIONS: Applicants must also complete the Child-Support Questions regarding any child-support
obligation. In accordance with N.J.S.A. 2A:17-56.44, any applicant who has an arrearage of child-support payments will be
permitted to take the examination if his or her application is approved; however, a license will not be issued to any candidate who
owes back child-support payments in excess of six (6) months. The information provided will be thoroughly checked.
APPLICATION FEE: An application fee of $100.00 must accompany this application. This fee should be paid in the form
of a check or money order made payable to the State of New Jersey. The application fee you submit with your application is
nonrefundable. (Applicants should understand that if the application ling fee is paid with a personal check, and the check is
returned by the bank due to insufcient funds, the next step in the examination process will be delayed until the fee is paid.)
AFFIDAVIT: The afdavit section of the application must be signed and notarized.
APPLICATION APPROVAL: If your application to take the Master Plumbers Examination administered by PSI SERVICES,
LLC. is approved, you will be notied in writing by the Board and the appropriate registration form(s) to take the examination
will be forwarded to you.
For further assistance, please call the Board Ofce at 973-504-6420.
Photo #1
New Jersey Office of Attorney General
Division of Consumer Affairs
State Board of Examiners of Master Plumbers
124 Halsey Street, 6th Floor, P.O. Box 45008
Newark, New Jersey 07101
(973) 504-6420
Application to Take the Examination to Become a Licensed Master Plumber
Application date: ____________________
Month Day Year
A nonrefundable application ling fee of $100, in the form of a check or money order made out to the State of New Jersey, must be
submitted with this application. (Applicants should understand that if the application ling fee is paid with a personal check, and the
check is returned by the bank due to insufcient funds, the next step in the examination process will be delayed until the fee is paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act
(OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Place of birth: ________________________
City State
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: ____________________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Photo #2
Attach two clear, full-face pass-
port-style photographs (2˝x 2˝)
of your head and shoulders, taken
within the past six months.
Two photographs are required
with each application.
Do not use staples to attach the
photographs.
3. Social Security Number
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: __________ -____________ - ___________
*Pursuant to N.J.S.A. 54:50-24 et seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7, 60.8 and 60.9, the Board or Committee is
required to obtain your Social Security number. Pursuant to these authorities, the Board or Committee is also obligated to provide
your Social Security number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records; and
b. the Probation Division or any other agency responsible for child-support enforcement, upon request.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
5. Student Loan
Are you in default in regard to any student loan obligation(s)? Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license unless you provide the required
documents concerning the plan for repayment of your student loan.
6. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation? Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months?
Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ ________________________
Applicant’s name (please print) Applicant’s signature Date
click to sign
signature
click to edit
7. Medical Conditions Questions
Questions a through f pertain to medical conditions and use of chemical substances. Please read the denitions carefully. Your
responses will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer those
portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity if you have
reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may assert
the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in good faith. If
you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on the applica
tion.
Your application for licensure or certication will be processed if you claim the Fifth Amendment privilege against self-incrimination.
You should be aware, however, that you may later be directed by the Attorney General to answer a question that you have refused
to answer on the basis of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory
law. (N.J.S.A. 45:1-20.)
“Ability to practice as a master plumber” is to be construed to include all of the following:
a. The cognitive capacity to exercise the reasonable judgments of a master plumber and to learn and keep abreast of professional
developments; and
b. The ability to communicate those judgments and related information to clients and other interested parties, with or without
the use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of a master plumber, with or without the use of aids or devices, such as corrective
lenses or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthope
dic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
dia
betes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
pre
scription for legitimate medical purposes and in accordance with the prescriber’s direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on one’s functioning as a licensee, or within the previous
two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g.
heroin or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or
not taken in accordance with the directions of a licensed health care practitioner.
a.
Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
b. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
c. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice?
Yes No Not applicable
d. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety?
Yes No Not applicable
e. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
f. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question f, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to
determine whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you
are not eligible for licensure or certication.
____________________________________________________ ___________________________________
Signature of applicant Date
click to sign
signature
click to edit
8. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
9. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
10. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
11. Do you currently hold, or have you ever held, a professional or occupational license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction?
Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
12. Have you ever been disciplined or denied a professional or occupational license or certicate of any kind in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
13. Have you ever had a professional or occupational license or certicate of any type suspended, revoked or surrendered in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
14. Has any action (including the assessment of nes or other penalties) ever been taken against your professional or occupational
practice by any agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
15. Have you ever been named as a defendant in any litigation related to the practice of plumbing or other professional or occupational
practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
16. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a
professional or occupational board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
17. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
18. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional or
occupational group related to the practice of plumbing or other professional or occupational practice in New Jersey, any other state,
the District of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 12 through 18, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
Education
1. What is the name and address of the high school you attended? _____________________________________________________
Name of high school
_______________________________________________________________________________________________________
Street address City State ZIP code
2. What years did you attend high school? _____________________
3. Did you graduate from high school? Yes No
If “Yes,” what was the date of your graduation? ____________________________
Month Year
If “No,” did you study to receive a G.E.D. certicate? Yes No
If “Yes,” please provide the name and address of the educational institution that issued your G.E.D. certicate and the date
the
certicate was issued.
_______________________________________________________________________________________________________
Name of educational institution
_______________________________________________________________________________________________________
Street address City State ZIP code
_______________________________________________________________________________________________________
Date certicate was issued
4. What is the name and address of the colleges, universities or vocational schools you have attended? (Use additional sheets of paper
if necessary.)
Name of college, university or vocational school
Street address City State ZIP code
Name of college, university or vocational school
Street address City State ZIP code
5. List all of the degrees, diplomas or certicates that you have received from recognized colleges, universities or vocational
schools. Please have each school forward directly to the Board the ofcial transcript for each degree, diploma or certicate that you have
earned.
Educational institution Inclusive years Degree, Major Date granted
Diploma or
Certicate
_______________________ ____________ ____________ ___________ _______________________
_______________________ ____________ ____________ ___________ _______________________
Statement of Employment (Work experience must have been attained under the supervision of a Licensed Master Plumber.)
An applicant for examination must present proof that he or she:
Has completed a four-year apprenticeship program approved by both the United States Department of Labor and a federally certied
state agency, and has completed one year of practical hands-on experience as a journeyman plumber; or
Has been awarded a bachelor’s degree in mechanical, plumbing or sanitary engineering from a college or university accredited by a
regional accreditation agency recognized by the Council on Post-Secondary Accreditation or the United States Department of Education,
and has completed one year of practical hands-on experience as a journeyman plumber.
1. Please list the experience you have acquired. Provide the information about your current (or most recent) employment rst.
(1) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name, title and license number: _______________________________________________________
___________________________________________________________________________________________________
(2) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name, title and license number: _______________________________________________________
___________________________________________________________________________________________________
(3) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name, title and license number: _______________________________________________________
___________________________________________________________________________________________________
(4) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name, title and license number: _______________________________________________________
___________________________________________________________________________________________________
(5) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name, title and license number: _______________________________________________________
___________________________________________________________________________________________________
(6) Employer: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________
Street address City State ZIP code
Telephone number: __________________________________
(include area code)
Title of your position: __________________________________________________ Hours per week: __________________
Your major responsibilities (use additional sheets of paper if necessary): __________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
From ____________________________________________ to ________________________________________________
Month Year Month Year
Immediate supervisor’s name, title and license number: _______________________________________________________
___________________________________________________________________________________________________
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: _____________________________________________
County of: ___________________________________________
I, ___________________________________________ , in making this application to the State Board of Examiners of
Master Plumbers for licensure or certication under the provisions of Title 45 of the General Statutes of New Jersey and the
Rules of the State Board of Examiners of Master Plumbers, swear (or afrm) that I am the applicant and that all information
provided in connection with this application is true to the best of my knowledge and belief. I understand that any omissions,
inaccuracies or failure to make full disclosures may be deemed sufcient to deny licensure or certication or to withhold
renewal of or suspend or revoke a license or certicate issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:14C-1 et seq., together with the Rules and Regulations of the State
Board of Examiners of Master Plumbers, N.J.A.C. 13:32-1.1 et seq., and fully understand that in receiving licensure from
the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for licensure or certication. I further authorize all institutions, employers, agen-
cies and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les
or records requested by the Board.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this _____________
day of _________________________ , ____________
Month Year
Afx Seal Here
_____________________________________________
Name of Notary Public (please print)
_____________________________________________
Signature of Notary Public
} ss.
(For ofce use only)
Location of examination: ________________________________________ Date: ______________________________
Was the applicant required to take the examination?
Yes No
Was the applicant approved?
Yes No
If the applicant was not approved, please state the reason: __________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Number of license issued: __________________ Date the license was approved by the Board: _____________________
Test score: ______________________________
New Jersey Office of Attorney General
Division of Consumer Affairs
State Board of Examiners of Master Plumbers
124 Halsey Street, 6th Floor, P.O. Box 45008
Newark, New Jersey 07101
(973) 504-6420
Work Experience Certication
(Please print in ink or type.)
Employer information
______________________________________________________________________________________________________
Last name First Middle
___________________________________________________________________________________________________________
Name of company
___________________________________________________________________________________________________________
Street address City State ZIP code
_______________________________
Telephone number (include area code)
This Work Experience Certication form properly completed on both sides by you, the employer, will assist the State Board of
Examiners of Master Plumbers in determining the qualications of the applicant for a master plumber’s license. Your answers will be
considered condential information by the Board.
The Board expects every person signing this Wo rk Experience Certification to understand that he or she is attesting to
the applicant’s good character, working skills and employment experience. Statements by responsible people with actual
knowledge of the applicant’s qualications will be considered by the Board as evidence of the above.
This form should be returned to the State Board of Examiners of Master Plumbers, at the above address, within 15 days, or the Board
will request that you appear personally.
Statement of Reference
(This form should not be lled out in the presence of the applicant.)
Applicant information
______________________________________________________________________________________________________
Last name First Middle
___________________________________________________________________________________________________________
Street address City State ZIP code
_______________________________
Telephone number (include area code)
1. How long have you known the applicant? ______________________________________
2. What is your relationship to the applicant? _____________________________________
3. How long was the applicant employed by you? Give the exact dates.
From _________________________________________________ to _______________________________________________
Month/Day/Year Month/Day/Year
From _________________________________________________ to _______________________________________________
Month/Day/Year Month/Day/Year
Date _________________________
Month/Day/Year
4. Please indicate (by putting a check in the appropriate box) applicant’s plumbing background while employed by you.
Helper : From _____________________________________________ to ________________________________________
Month/Day/Year Month/Day/Year
Journeyman: From _________________________________________ to ________________________________________
Month/Day/Year Month/Day/Year
5. What were the applicant’s duties while employed by you? ______________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
6. What is your business or profession? _________________________________________________________________________
7. Are you a New Jersey Licensed Master Plumber?
Yes No
If “Yes,” what is your New Jersey Master Plumber’s license number? _______________________________________________
Are you licensed in any other state or jurisdiction? Yes No
If “Yes,” please provide the state or jurisdiction and license number: _______________________ ____________________
State or jurisdiction License number
8. Are you a personnel director or the representative of a rm? Yes No
If “Yes,” please provide the following information:
__________________________________________________________________________________________________
Last name First Middle
_______________________________________________________________________________________________________
Street address City State ZIP code
___________________________ ____________________________________
Telephone number (include area code) Title
9. If you are not a Licensed Master Plumber, give the name, address, telephone number and license number of the Licensed Master
Plumber who supervised the applicant.
__________________________________________________________________________________________________
Last name First Middle
_______________________________________________________________________________________________________
Street address City State ZIP code
___________________________ ____________________________________
Telephone number (include area code) Title
I certify that the above information is correct to the best of my knowledge. I understand that if I certify false statements,
I am subject to punishment.
_________________________________________
Signature
__________________________________________
Date
Ifyouhaveanyadditionalinformation,pleaseprovideit.
N.J. seal
press,
if applicable.
New Jersey Office of Attorney General
Division of Consumer Affairs
State Board of Examiners of Master Plumbers
124 Halsey Street, 6th Floor, P.O. Box 45008
Newark, New Jersey 07101
(973) 504-6420
Work Experience Certication
(Please print in ink or type.)
Employer information
______________________________________________________________________________________________________
Last name First Middle
___________________________________________________________________________________________________________
Name of company
___________________________________________________________________________________________________________
Street address City State ZIP code
_______________________________
Telephone number (include area code)
This Work Experience Certication form properly completed on both sides by you, the employer, will assist the State Board of
Examiners of Master Plumbers in determining the qualications of the applicant for a Master Plumber’s license. Your answers will be
considered condential information by the Board.
The Board expects every person signing this Wo rk Experience Certification to understand that he or she is attesting to
the applicant’s good character, working skills and employment experience. Statements by responsible people with actual
knowledge of the applicant’s qualications will be considered by the Board as evidence of the above.
This form should be returned to the State Board of Examiners of Master Plumbers, at the above address, within 15 days, or the Board
will request that you appear personally.
Statement of Reference
(This form should not be lled out in the presence of the applicant.)
Applicant information
______________________________________________________________________________________________________
Last name First Middle
___________________________________________________________________________________________________________
Street address City State ZIP code
_______________________________
Telephone number (include area code)
1. How long have you known the applicant? ______________________________________
2. What is your relationship to the applicant? _____________________________________
3. How long was the applicant employed by you? Give the exact dates.
From _________________________________________________ to _______________________________________________
Month/Day/Year Month/Day/Year
From _________________________________________________ to _______________________________________________
Month/Day/Year Month/Day/Year
Date _________________________
Month/Day/Year
4. Please indicate (by putting a check in the appropriate box) applicant’s plumbing background while employed by you.
Helper : From _____________________________________________ to ________________________________________
Month/Day/Year Month/Day/Year
Journeyman: From _________________________________________ to ________________________________________
Month/Day/Year Month/Day/Year
5. What were the applicant’s duties while employed by you? ______________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
6. What is your business or profession? _________________________________________________________________________
7. Are you a New Jersey Licensed Master Plumber?
Yes No
If “Yes,” what is your New Jersey Master Plumber’s license number? _______________________________________________
Are you licensed in any other state or jurisdiction? Yes No
If “Yes,” please provide the state or jurisdiction and license number: _______________________ ____________________
State or jurisdiction License number
8. Are you a personnel director or the representative of a rm? Yes No
If “Yes,” please provide the following information:
__________________________________________________________________________________________________
Last name First Middle
_______________________________________________________________________________________________________
Street address City State ZIP code
___________________________ ____________________________________
Telephone number (include area code) Title
9. If you are not a Licensed Master Plumber, give the name, address, telephone number and license number of the Licensed Master
Plumber who supervised the applicant.
__________________________________________________________________________________________________
Last name First Middle
_______________________________________________________________________________________________________
Street address City State ZIP code
___________________________ ____________________________________
Telephone number (include area code) Title
I certify that the above information is correct to the best of my knowledge. I understand that if I certify false statements,
I am subject to punishment.
_________________________________________
Signature
__________________________________________
Date
Ifyouhaveanyadditionalinformation,pleaseprovideit.
N.J. seal
press,
if applicable.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application to Take the Examination to Become a (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 August 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document