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

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

11. Are you the subject

11. Are you the subject of pending disciplinary actions by a licensing 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):_______________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 12. 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):_______________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 13. 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):_______________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 14. Have you ever been convicted of a felony or misdemeanor in the United States or any country or foreign jurisdiction, other than a traffic violation for which a fine of less than $100.00 was assessed? If yes, please state the details (use a separate sheet if necessary):_______________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 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. 15. 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 Registration in 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, S. 49A., to the best of my knowledge and belief, I have filed all state tax returns and paid all state tax required by law. ___________________________________________________ Signature of Applicant _________________________________ Date Subscribed and sworn to, before me, this ______________________ day of ___________________________20___________ Notary Signature__________________________________________________________________________________________ NOTARIAL SEAL My commission expires:____________________________________________________________________________________ 2” x 2” passport photograph. Please attach a photograph taken no longer than 6 months ago. F

VISA, Mastercard, Money Order or Cashier’s Check only. Credit card (MasterCard or VISA) payment accepted for phone or fax review/re-exam registrations only. MC Visa Card No:___________________________________________________________ Exp. Date:________________________________ Card Verification No:__________________ For your security, PSI requires you to enter the card identification number located on your credit card. The card identification number is located on the back of the card and consists of the last three digits on the signature strip. Cardholder Name (Print):______________________________________ Signature:___________________________________________

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