Fillable Reinstatement App 0 (Commonwealth of Massachusetts)

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Reinstatement App 0 (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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TEL: 617-727-9952
FAX: 617-727-6095
TTY/TDD: 617.727.2099
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.
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:
______ ________________________________ __________________________ _____ ________
Number Name City/Town State Zip Code
______ ________________________________ __________________________ _____ ________
Number Name City/Town State Zip Code
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
Signature of Verifying DPL Employee 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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Reinstatement App 0 (Commonwealth of Massachusetts)

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Completed 27 July 2020

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