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http://www.mass.gov/dpl/boards/pl
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
APPLICATION FOR REINSTATEMENT OF EXPIRED LICENSE
Continuing education requirements for reinstatement of expired licenses are established by the Board of State Examiners of Plumbers and
Gas Fitters in regulation 248 CMR 11.04 (5) and may be viewed on the Board’s website at: www.mass.gov/dpl/boards/pl.
PLEASE PRINT CLEARLY
Last Name: ___________________________________First Name: _____________________Middle Initial:_____
Residence: ______ ____________________________________ _____________________ ____ _________
Number Address City/Town State Zip Code
Home Phone: __________________ Cell Phone: __________________ email: ____________________________
Social Security Number (Last six digits only): _____ - ____________ Date of Birth: ________________
License Number to be reinstated:
AP:________ JP:________ MP:________ AG:________ JG:________ MG:________ LP:_______
In the time that your license has been expired, has a licensing/certification board located in the United States or any country or foreign
jurisdiction taken any disciplinary action against you, or are you the subject of any open or pending action? Yes
No
If yes, please provide detailed information.
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
During the time your license was expired, have you held yourself out as a plumber or gas fitter or otherwise practiced plumbing or gas
fitting in Massachusetts? Yes
No If yes, please explain
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
In the time that your license has been expired have you been convicted of a felony or misdemeanor other than a traffic violation in the
United States or any country or foreign jurisdiction? Yes
No If yes, please provide detailed information.
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
The Board is certified by the Massachusetts 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 the licensing process.
I hereby subscribe to and vouch for the statements made herein to be accurate and true in every respect and I am signing this document
of my own free will without coercion this_____ day of _____________________________ _ 20_____.
Signature of Applicant
You must attach all continuing education certificates to this application relative to the time your license was expired.
Upon application review, the Board may request additional information or impose additional requirements for reinstatement, including
continuing education, additional education and/or passing the appropriate examination.