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

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

The Commonwealth

The Commonwealth of Massachusetts Division of Registration BOARD OF STATE PLUMBERS AND GAS FITTERS 1000 Washington St., 7th Floor Boston, Masachusetts 02118 STATEMENT OF EXPERIENCE FOR UNDILUTED LIQUEFIED PETROLEUM GAS INSTALLERS Erasures, Mark Overs or White Outs are Unacceptable Print Name Neatly________________________________________________________________________________________________ First Middle Last Applicant’s Residence_____________________________________________________________________________________________ Number Street City or Town Zip Code EMPLOYERS STATEMENT This is to certify that ________________________________________________________________trained under a licensed individual: _____________________________________________________to _________________________________________________________ Month/Day/Year Month/Day/Year Can you produce Social Security Records for this person Yes No Signature of Employer_____________________________________________________________________________________________ Business Firm Name_______________________________________________________________________________________________ Business Address__________________________________________________________________________________________________ As the employer I hereby certify that the above statements are true and are made subject to the penalties of perjury. THE APPLICANT MUST SIGN THIS APPLICATION IN THE PRESENCE OF A NOTARY PUBLIC I do solemnly swear (affirm) that I am the applicant named in this statement of experience, that I have made or read the contents thereof, and to the best of my knowledge and belief the foregoing statements and answers are true in substance and made in good faith. (Signature of Applicant) Subscribed and sworn to before me this ____________________________day of _____________ 20___________ _________________________________________ Notary Public Signature NOTARY SEAL My commission expires______________________________________________________________________ K

BOOKS AND MORE ARE NOW AVAILABLE AT THE PSI ONLINE STORE! To place an order for one or more of the following items listed, you may: Call the PSI Online store toll-free at (866) 589-3088 CERTIFICATE OF ACHIEVEMENT (You must have passed the exam before ordering the certificate) Certificate of Achievement suitable for framing. $18.00 plus shipping and handling. NFPA 54 National Fuel Gas Code 29 CFR Part 1926 Selections Please note: Inventory and pricing subject to change without notice. You may also place a checkmark next to the items that you would like to order, and fax this form to PSI (be sure to include your contact information). A Customer Service Rep will call you to place the order. FAX to: PSI licensure:certification Fax (702) 932-2668 Name_________________________________________________________________________________________ Address________________________________________________________________________________________ City______________________________________________________State______________________Zip________ Phone Number__________________________________________________________________________________

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