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APPLICATION FOR ELECTRICAL CONTRACTORS EXAMINATION
AND LICENSE
FOR THE CITY OF MISHAWAKA, INDIANA |
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NAME OF APPLICANT:
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______________________________ |
DATE:
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| Applicant's SSN: ______________________________ |
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If applicant represents a firm or corporation, give firm name and names of officers: _________________________
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ADDRESSES:
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TELEPHONE NUMBERS:
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Business:
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___________________________
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Business:
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___________________________
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___________________________
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___________________________
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Residence:
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___________________________
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Residence:
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___________________________
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___________________________
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Applicant's Age:
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___________________________
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OCCUPATION FOR LAST FIVE (5) YEARS:
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Firm Name and Address: ____________________________________________________________________
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Phone No.: _______________
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Duties: _______________
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Years: _______________
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Firm Name and Address: ____________________________________________________________________
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Phone No.: _______________
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Duties: _______________
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Years: _______________
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Firm Name and Address: ____________________________________________________________________
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Phone No.: _______________
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Duties: _______________
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Years: _______________
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(List any other on the reverse side)
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YEARS OF EXPERIENCE -
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As Journeyman ______________
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As Contractor ______________
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Have you ever been examined for Journeyman or Heating/AC Contractor
in any other city or state?________
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Where? _______________
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Date? ________________
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Journeyman: ___________________
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Heating/AC Contractor: ____________________________
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Were you successful? _____
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Names of the Secretaries of the Boards giving examinations
____________________________________________________________________________________
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EDUCATION - Years
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Grade School: _____
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High School: _____
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Trade School: _____
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Night School: _____
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Others: ________
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A FEE OF $10.00 MUST ACCOMPANY THIS APPLICATION
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STATE OF INDIANA )
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)
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SS:
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ST. JOSEPH COUNTY)
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_________________________________, being duly sworn upon his oath,
deposes and says that all statements
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(Name of Applicant)
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made in the above application are true, and said statements are
made for the purposeof securing an examination and obtaining a license
as an Electrical Contractor in the County of St. Joseph, Indiana.
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Subscribed and sworn to before me, a Notary Public, in and for
said County and State, this ________________ day of _____________________________,
__________. My commission expires on _____________________.
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_____________________________________________
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Notary Public, Residing in St. Joseph County, Indiana
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