Fillable Commonwealth of Massachusetts Journeyman Plumber Examination Application

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Commonwealth of Massachusetts Journeyman Plumber Examination Application

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The Commonwealth of Massachusetts
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF STATE EXAMINERS OF PLUMBERS AND GAS FITTERS
1000 Washington Street, Suite 710 – Boston, Massachusetts 02118-6100
J
OURNEYMAN PLUMBER
EXAMINATION APPLICATION
If you are filling this out by hand, PLEASE PRINT CLEARLY
NOTE: $31.00 Application Fee – Make check or money order payable to the Commonwealth of Massachusetts
APPLICANT INFORMATION
A
pplication Date:_____________
Last Name: ___________________________________First Name: _____________________Middle Initial:_____
Maiden Name, Former Name, Also Known as, if applicable:
Other Last Name Other First Name Other Middle Initial:
Gender: Male:
Female: Prefer not to answer:
Mailing Address: _____ ___________________________________ _____________________ ____ _______
Number Street City/Town State Zip Code
Home Phone: _______________ Cell Phone: _______________ email: __________________________________
Please note: EMAIL is the primary means of contact for routine correspondences during the application process.
Social Security Number (Mandatory): ________________________________ Date of Birth: ________________
Pursuant to G.L. c.62C, s. 47A, the Division of Professional Licensure is required to obtain your social security number and forward it to the
Department of Revenue. The Department of Revenue will use your social security number to ascertain whether you are in compliance with the
tax laws of the Commonwealth.
Has any disciplinary action been taken against you by a licensing/certification board located in the United States or
any country or foreign jurisdiction? Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Are you the subject of pending disciplinary actions by a licensing/certification board located in the United States or
any country or foreign jurisdiction? Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Page 1
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification board in the
United States or any country or foreign jurisdiction? Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever applied for and been denied a professional license in the United States or any country or foreign
jurisdiction? Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever been convicted of, or admitted to, a felony or misdemeanor in the United States or any country or
f
oreign jurisdiction? Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
___________________________________________________________________________________________
Have you ever been charged with a criminal violation which led to a disposition of “continued without a
finding”(“CWOF”) or admission to sufficient facts? Yes:
No:
I
f yes, please state the details (use a separate sheet if necessary):
____
_______________________________________________________________________________________
List all professional licenses/certifications you have held in the United States, or any country or jurisdiction, and the
state/jurisdiction from which the license/certification was originally issued.
Type of License: Jurisdiction: License Number:
Type of License: Jurisdiction: License Number:
MILITARY STATUS
Please check the appropriate box: Active Duty: Spouse: Veteran: Not Applicable:
P
age 2
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
EDUCATION VERIFICATION FORM A
Apprentice License Number:_______________
Do you have a High School Diploma or GED? Yes: No:
If yes, please include with this application a copy of your diploma, transcripts or G.E.D. for Board review.
If no, please contact the Board for further information. Please note, a high school diploma or G.E.D. is required to
apply for this license.
Have you completed the required hours of apprentice education training (300 hours) Yes: No: .
If no, please contact the Board for further information. Please note, 300 hours of classroom education is required
for all individuals who were issued an apprentice license prior to September 1, 2008.
Have you completed the required hours of work experience (5100 hours) Yes: No: .
If no, please contact the Board for further information. Please note, 5100 hours of supervised work experience is
required for all individuals who were issued an apprentice license prior to September 1, 2008.
The section directly below MUST be completed by school officials
Subject to the rules set forth in Section 4 of Chapter 142 of the General Laws, I attest the following information is correct:
Name of Apprentice Plumber Name of School
Date of Enrollment Date Course was Completed
During that time, this student successfully completed the following classroom education meeting the requirements of 248 CMR 11.00:
Hours of basic pl
umbing and gas fitting theory necessary for the Journeyman Plumbing Exam
As a full time Vocational high School student who graduated with a plumbing certificate, this student successfully completed:
hours of supervised hands on work experience and obtained hours of plumbing and gas fitting classroom education
Name and Title of Designated School Official – Type or Print Signature of Designated School Official
Name of Plumbing Instructor Master License Number Signature of Plumbing Instructor
School Phone Number
Plumbing Instructor email address Date
Page 3
PHONE: 617 727-9952 FA
X: 617 727-6095
www.mass.gov/dpl/boards/pl
THIS PAGE SHOULD ONLY BE FILLED OUT BY APPRENTICE PLUMBERS
WHO QUALIFY FOR THE 3 YEAR WORK EXPERIENCE,
300 HOUR EDUCATIONAL PROGRAM.
APPLICANTS WHO WERE ISSUED THEIR LICENSE PRIOR TO SEPTEMBER 1, 2008
EDUCATION VERIFICATION FORM B
Apprentice License Number:_______________
Do you have a High School Diploma or GED? Yes: No:
If yes, please include with this application a copy of your diploma, transcripts or G.E.D. for Board review.
If no, please contact the Board for further information. Please note, a high school diploma or G.E.D. is required to
apply for this license.
Have you completed the required hours of apprentice education training (550 hours) Yes: No: .
If no, please contact the Board for further information. Please note, 550 hours of Tier structured classroom
education is required for all individuals who were issued an apprentice license after September 1, 2008.
Have you completed the required hours of work experience (8500 hours) Yes: No: .
If no, please contact the Board for further information. Please note, 8500 hours of supervised work experience is
required for all individuals who were issued an apprentice license after September 1, 2008.
The section directly below MUST be completed by school officials
Subject to the rules set forth in Section 4 of Chapter 142 of the General Laws, I attest the following information is correct:
Name of Apprentice Plumber Name of School
Date of Enrollment Date Course was Completed
During that time, this student successfully completed the following classroom education meeting the requirements of 248 CMR 11.00:
110 hour Tier 1 First Year lesson for Journeyman Plumber Licensure
110 hour Tier 2 Second Year lesson for Journeyman Plumber Licensure
110 hour Tier 3 Third Year lesson for Journeyman Plumber Licensure
110 hour Tier 4 Fourth Year lesson for Journeyman Plumber Licensure
110 hour Tier 5 Fifth Year lesson for Journeyman Plumber Licensure
As a full time Vocational high School student who graduated with a plumbing certificate, this student successfully completed:
hours of supervised hands on work experience
Name and Title of Designated School Official – Type or Print Signature of Designated School Official
Name of Plumbing Instructor Master License Number Signature of Plumbing Instructor
School Phone Number Plumbing Instructor email address Date
PHONE: 617 727-9952
Page 4
FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
THIS PAGE SHOULD ONLY BE FILLED OUT BY APPRENTICE PLUMBERS
WHO QUALIFY FOR THE 5 YEAR WORK EXPERIENCE,
550 HOUR TIER EDUCATIONAL PROGRAM.
APPLICANTS WHO WERE ISSUED THEIR LICENSE AFTER SEPTEMBER 1, 2008
STATEMENT OF EXPERIENCE FORM
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 MI Last
Address; _______ ________________________________________ _________________________ _______
Number Street City or 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
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 MI Last
Address: _______ ______________________________________ ________________________ _______
Number Street City/Town Zip Code
___________________ _________________
Master License Number Original Date of Issue
Phone Number: __________________________ email: _________________________________________
Busines
s Name (if applicable): _______________________________________________________________
_____________________ _________________
Business Licence Number Original Date of Issue
Can you produce Social Security Rec
ords for this person? Yes No
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: ________________________________________________________________
FORM MUST BE ORIGINAL – PHOTO-COPY OF THESE SHEETS ARE UNACCEPTABLE
Page 5
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
YOU MUST INCLUDE THIS
APPLICATION CHECKLIST
WITH YOUR APPLICATION
□ I have included a 2” x 2” color passport photo
□ I have included high school diploma, transcripts or G.E.D.
□ I have included certificates of completion from a Board approved Training program
□ I have included the “Statement of Experience” form
□ I have included the “Education Verification” form A or B (only submit one)
□ I have included the “CORI Authorization Form”
□ I have included the $ 31.00 non-refundable application / license fee payable to the
“Commonwealth of Massachusetts”
□ VETERANS ONLY: I have included a copy of my DD form 214
Pursuant to G.L. c. 62C, § 47A, the Division of Professional Licensure is required to obtain your
social security number and forward it to the Department of Revenue. The Department of
Revenue will use your social security number to ascertain whether you are in compliance with
the tax laws of the Commonwealth.
Signature of applicant Date of Birth (mm/dd/yyyy) Date
Mail your completed application to:
Board of Examiners of Plumbers and Gas Fitters
1000 Washington Street – Suite 710
Boston, MA, 02118-6100
Page 6
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
The Board is certified by the Criminal History Systems Board {ID#MAREG G} to access data about convictions and pending
criminal cases. Those records – and other Federal and professional records – may be checked as part of your licensing
process. No records are automatic disqualifiers; you will be given an opportunity for a limited appearance before the Board of
State Examiners of Plumbers and Gas Fitters.
THE FOLLOWING IS TO BE COMPLETED IN THE PRESENCE OF A NOTARY.
I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application
for licensure is truthful and accurate. I understand that the failure to provide accurate information may be grounds
for the Massachusetts Board of Examiners of Plumbers and Gas Fitters to deny me the right to sit as a candidate or
to suspend or revoke a license issued to me in accordance with Massachusetts Law. I further attest that, pursuant
to G.L. c.62C, §49A, to the best of my knowledge and belief, I have filed all Massachusetts tax returns and paid all
Massachusetts taxes required by law.
Signature of Applica
nt ____________________________________ Date _______________________
Notary Name (print) _______________________________________
Notary Signature _________________________________________ Commission Expires ___________
Page 7
Please affix
2” x 2”
Passport Photo Here
NOTARY SEAL
PHONE: 617 727-9952
FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Divis
ion of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified
prospective license applicants and current licensees.
As a lic
ense applicant or current licensee, I understand that a CORI check will be submitted for my
personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby
acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check
for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I
may withdraw this authorization at any time by providing the Division of Professional Licensure written
notice of my intent to withdraw consent to a CORI check.
FOR LICE
NSING PURPOSES ONLY:
The Divis
ion of Professional Licensure may conduct subsequent CORI checks within one year of the
date this Form was signed by me. If subsequent CORI checks are necessary, the Division of
Professional Licensure will provide me with written notice of the subsequent CORI checks.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided
on Page 2 of this Acknowledgement Form is true and accurate.
_________________________________ _________________________________
Signature Date
Please provide the name of the board of registration and license type for which you are applying or currently hold:
_________________________________ _________________________________
Board of R
egistration License Type
NOTE: D
PL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS IT IS
EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS LIKEWISE
VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE BOARD'S OFFICES
AT THE ADDRESS SET FORTH ABOVE.
Page 1 of 2
SUBJECT INFORMATION: (A red asterisk (*) denotes a required field)
___________________________________________________________________________________
*Last Name *First Name Middle Name Suffix
___________________________________________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________
____________________________
*Date of Birth Place of Birth
*Last Six Digits of Your Social Security Number: ______ - _____________
S
ex: ______ Height: ____ ft. ____ in. Eye Color: ___________
Driver’s License or ID Number: ___________________ State of Issue: ________________________
Current and Former Addresses:
___________________________________________________________________________________
Street Number & Name City/Town State Zip
___________________________________________________________________________________
Street Number & Name City/Town State Zip
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the
above-referenced subject by reviewing the following form(s) of government-issued identification:
1
Passport State-issued driver’s license Military identification State-issued identification card
VERIFIED BY:
Name of Verifying DPL Employee (Please Print)
Signature of Verifying DPL Employee (Please Print) Date
SECTION B: VERIFICATION BY NOTARY:
O
n this ______ day of _____________, 20____, before me, the undersigned notary public, personally
appeared _________________________________ (name of document signer), and proved to me
through satisfactory evidence of identification, which was the following:
1
Passport State-issued driver’s license Military identification State-issued identification card
to be the pe
rson whose name is signed on the preceding or attached document, and acknowledged to
me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public: Notary Commission Expires On:
1
If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by the other
forms of identification documentation as determined by DCJIS. 803 CMR 2.09 (2).
Page 2 of 2
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Commonwealth of Massachusetts Journeyman Plumber Examination Application

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Completed 10 May 2020

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