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Board of State Examiners of Plumbers and Gas Fitters ... - PSI

Board of State Examiners of Plumbers and Gas Fitters ... - PSI

IMPORTANT MASTER GAS

IMPORTANT MASTER GAS FITTER AND JOURNEY GAS FITTER APPLICANTS MUST COMPLETE PAGES E-H ONLY. UNDILUTED LP GAS INSTALLER APPLICANTS MUST COMPLETE PAGES I-K ONLY.

The Commonwealth of Massachusetts Division of Professional Licensure BOARD OF STATE PLUMBERS AND GAS FITTERS 1000 Washington St., 7th Floor Boston, Massachusetts 02118 EXAMINATION APPLICATION (Check one) Master Gas Fitter Examination Journeyman Gas Fitter Examination 1. Applicant Name___________________________________________________________________________________________ Last First Middle 2. Permanent Address________________________________________________________________________________________ No. Street Apt. # 0 City/Town State Zip Code 3. Business (If Applicable)____________________________________________________________________________________ No. Street Apt. # City/Town State Zip Code 4. Which address should appear on your license? Permanent Business 5. Date of Birth_____________________________________ Place of Birth___________________________________________ 6. Maiden Name/Other Name__________________________________________________________________________________ 7. Telephone Number Day_____________________________________________ Evening_______________________________ 8. Social Security Number (Mandatory)__________________________________________________________________________ Pursuant to G.L. c.62C, s. 47A, the Division of Registration 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. 9. List any licenses/certifications you hold in the United States or any country of foreign jurisdiction and the state/jurisdiction from which the license/certification was originally issued. Please attach a certificate of standing from each state or jurisdiction in which you are licensed/certified, indicating the status of your license and any relevant disciplinary information _________________________________________________________________________________ _______________________________________________________________________________________________________ 10. 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):_______________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ E

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