Commonwealth of Massachusetts Office of Consumer Affairs
DIVISION OF PROFESSIONAL LICENSURE
Board of State Examiners of Plumbers and Gasfitters
1000 Washington Street, Suite 710, Boston, Massachusetts 02118-6100
STATEMENT OF EXPERIENCE FOR PLUMBERS
EMPLOYEE STATEMENT
This section must be filled out by the Apprentice Plumber
Erasures, Mark Overs or White Outs will not be accepted
Name of Apprentice Plumber: ______________________ ___________ _____________________________
First
Middle
Last
Address: ________ _____________________________________ _______________________ __________
Number Street City/Town Zip Code
_______________________ ___________________
Apprentice License Number Date of Issue
EMPLOYERS STATEMENT
This section must be filled out by the employing Master Plumber
This is to certify that: was directly employed by me on
my payroll as a properly licensed Apprentice while performing properly supervised plumbing from:
to _____
Month Day Year Month Day Year
(to present is unacceptable)
Total hours the licensed Apprentice was directly employed by me performing supervised plumbing:___________
Note: Vocational school Co-op employment hours may not be included.
Name of Master Plumber: ______________________ ___________ ______________________________
First
Middle
Last
Address: ________ _____________________________________ _______________________ ________
Number Street City/Town Zip Code
Business Name (if applicable): ________________________________________________________________
Phone Number: __________________________ email: ___________________________________________
___________________
Original Date of Issue
___________________ _____________________ _________________
Master License Number Business License Number
Original Date of Issue
Can you produce Social Security Records for this person?
Yes No
As the employer I hereby certify that the above statements are true and are made subject to the penalties of perjury.
In addition, I certify that for the entire time listed above, the applicant worked for me as an apprentice plumber and
not as an independent contractor or a subcontractor performing non-plumbing work.
Signature of Employing Master Plumber
PHOTOSTATS OF THESE SHEETS ARE UNACCEPTABLE
click to sign
signature
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