Fillable Commonwealth of Massachusetts Limited LP Gas Installer Examination Application

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Commonwealth of Massachusetts Limited LP Gas Installer Examination Application

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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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
LIMITED LP GAS INSTALLER
EXAMINATION APPLICATION
PLEASE PRINT CLEARLY
NOTE: $66.00 Application Fee – Make check or money order payable to the Commonwealth of Massachusetts
APPLICANT INFORMATION
Application 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):
___________________________________________________________________________________________
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Page 1
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
foreign 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:
If 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:
Page 2
PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/pl
Have you completed the required ten (10) hour Occupational Safety and Health Administration course in
construction safety and health? Yes: No:
If no, please contact the Board for further information. Please note the ten (10) hour Occupational Safety and
Health Administration course is required for all individuals who are requesting permission to take the Limited LP
Installer exam.
Have you completed the required hours of 1000 hours of general work experience on construction sites certified by
a supervisor holding a non-apprentice professional construction license? Yes: No:
If no, please contact the Board for further information. Please note, 1000 hours of supervised work experience is
required for all individuals who are requesting permission to take the Limited LP Installer exam.
Have you completed the required hours of 700 hours of work experience installing, connecting and moving from
place to place undiluted liquefied petroleum gas salamanders, space heaters and related equipment used in
buildings under construction on construction sites while under the direct supervision of LTD LP Installer, LP
Installer, Journeyman plumber, Journeyman gas fitter, Master plumber or Master gas fitter? Yes: No:
If no, please contact the Board for further information. Please note, 700 hours of supervised LP work experience is
required for all individuals who are requesting permission to take the Limited LP Installer exam.
Page 3
PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/pl
VERIFICATION OF SCHOOL AND SHOP HOURS FOR THE
LIMITED LP INSTALLER PROGRAM
STATEMENT OF EXPERIENCE FORM
LP INSTALLER VERIFICATION OF EMPLOYMENT
The section directly below MUST be completed by the employing LP Installer
This is to certify that: was employed by me as a Limited
LP Installer in training performing supervised LP work from:
To
Month/Day/Year Month/Day/Year (to present is unacceptable)
Total hours employed as an LP Installer in training supervised LP work during this time:
Company or Name (If Applicable)
Name of Licensed Employer (Please Print)
License Information
License Type License Number Date of Issue Serial Number on License
Address
Number Street City or Town State Zip Code
Phone email:
Can you produce Social Security Records for this person? Yes No
If you checked NO in the box above, please explain
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 LP Installer in training and not as an independent
contractor or a subcontractor performing non-LP work.
Signature of Employer:
FORM MUST BE ORIGINAL – PHOTO-COPY OF THESE SHEETS ARE UNACCEPTABLE
Page 4
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 a copy of my OSHA 10 Card
I have included the “Statement of Experience” form
I have included the “CORI Authorization Form”
I have included the $ 66.00 non-refundable application / license fee payable to the
“Commonwealth of Massachusetts”
MANDATORY
My social security number is:
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 5
PHONE: 617 727-9952 FAX: 617 727-6095
www.mass.gov/dpl/boards/pl
Page
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 Applicant ____________________________________ Date _______________________
Notary Name (print) _______________________________________
Notary Signature _________________________________________ Commission Expires ___________
Page 6
NOTARY SEAL
Please affix
2” x 2”
Passport Photo Here
PHONE: 617 727-9952 FAX: 617 727-6095 www.mass.gov/dpl/boards/pl
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division 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 license 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 LICENSING PURPOSES ONLY:
The Division 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 Registration License Type
NOTE: DPL 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: (An 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: ______ - _____________
Sex: ______ 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:
On 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 person 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 Limited LP Gas Installer Examination Application

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Completed 10 May 2020

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