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Westchester County Contractor - Plumbers License

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					                 WESTCHESTER COUNTY BOARD OF PLUMBING EXAMINERS

Robert P. Astorino                                                                                 Timothy C. Idoni
County Executive                                                                                   County Clerk

                           MASTER  PLUMBER’S  TEST  APPLICATION

1)      NAME:

2)      DATE OF BIRTH:              ______________                *SS#                    -        -
                                                                Required for child support background checks
3)      HOME STREET ADDRESS:

4)      CITY:__________ STATE:                                    ZIP:                  PHONE: _________

5)      NAME OF COMPANY:

6)      COMPANY STREET ADDRESS:

7)      CITY: _________ STATE:                                  ZIP:                    PHONE: _________

8)      EDUCATION:

9)      APPRENTICE SERVICE:

10)     FIELD EXPERIENCE:

11)     HAVE YOU EVER BEEN APPROVED TO TAKE THIS EXAM BEFORE?
                  YES            NO

12)     HAVE YOU EVER BEEN CONVICTED OF ANY CRIME, FELONY,
        MISDEMEANOR OR VIOLATION?
                  YES             NO
                      If yes list information on a separate sheet of paper.

ALL APPLICANTS MUST HAVE SUCCESSFULLY COMPLETED A FOUR (4) YEAR
APPRENTICE PROGRAM WITH A LICENSED MASTER PLUMBER AND HAVE FIVE
(5) YEARS EXPERIENCE AT THE JOURNEY LEVEL, OR HAVE FIVE (5) YEARS
APPRENTICESHIP IN THE EMPLOY OF A LICENSED MASTER PLUMBER AND HAVE
FIVE (5) YEARS ADDITIONAL EXPERIENCE AS A JOURNEY LEVEL PLUMBER IN
THE EMPLOY OF A LICENSED MASTER PLUMBER. DOCUMENTATION MUST BE
PROVIDED WITH THIS APPLICATION.**


              110 Dr. Martin Luther King, Jr. Blvd. 3rd Floor White Plains, New York 10601 (914) 995-2657
*Social Security numbers are used by the County  Clerk’s  Office  for  State  Mandated  child  support  
background checks.

**Submission of W-2 forms as documentation is not required unless you wish to use them as proof of
prior employment, in which case you may omit your social security number from such forms.


NOTE: THIS APPLICATION MAY BE FILED IN PERSON OR BY MAIL AT THE
WESTCHESTER COUNTY CLERK – TRADES LICENSING DIVISION WITH THE
$50.00 APPLICATION FEE PAYABLE TO THE WESTCHESTER COUNTY CLERK.
YOU MUST ALSO PROVIDE TWO (2) FORMS OF I.D., ONE OF WHICH MUST BE
A PHOTO I.D.

                                    EXPERIENCE AND EDUCATION
                               (Attach documentation to support)




                                     CERTIFICATION
                                (Must be signed before a notary)

        I certify that the information on this form is true and
        accurate and understand that any incomplete, inaccurate or
        false information may cause my Westchester County Plumbing
        License to be delayed, denied or revoked.

        _____________________ ____________________ __________
        Applicant’s  signature  Print  name        Date

        Subscribed and sworn to before me this ___ day of
        ____________ 20__ in the County of __________________,
        State of ________________


                                                _____________________________
                                                Signature of Notary
                 WESTCHESTER COUNTY BOARD OF PLUMBING EXAMINERS

Robert P. Astorino                                                                                            Timothy C. Idoni
County Executive                                                                                              County Clerk

                        PROOF OF EMPLOYMENT AS A JOURNEYMAN FOR
                                THE MASTER PLUMBRS EXAM


DATE

COMPANY NAME

ADDRESS

CITY                                                       STATE                                              ZIP

LICENSE NO._________                           _WHERE LICENSED________________________

NAME OF LICENSE HOLDER____________________________________

                      Has been employed full time as a journeyman working
     NAME
Installing, removing, altering, replacing, testing or repairing of
plumbing systems in or on buildings for the above named company.

The dates of employment have been as follows:                                                                   to               .

By signing this letter, I attest under penalty of law, including the
possible suspension or revocation of my license, that, to my knowledge,
all the statements contained herein are true and accurate, and that if
requested by the Westchester County Board of Plumbing Examiners, I will
be able to provide the necessary payroll records to back up the dates of
employment.


Sworn to before me this                                               day of                                  , 20


Licensed Master Plumbers Signature (required)


Notary Public

                                                                                         Seal

                110 Dr. Martin Luther King, Jr. Blvd. 3rd Floor White Plains, New York 10601 (914) 995-2657 Fax (914) 995-3092
PROOF OF EMPLOYMENT LETTER AS A JOURNEYMAN
FOR THE MASTER PLUMBERS EXAM MUST BE
INCLUDED WITH THE APPLICATION ALONG WITH
PROOF OF TEN (10) YEARS FULL TIME EMPLOYMENT
BELOW

Examples of proof of experience in order to qualify for taking the
Plumbing License Examination are, but not limited to, any of the
following:

(A)   W-2 Forms
      Must include License Number and where License is held.
(B)   1040 Forms
(C)   Business Tax Statements
(D)   Notarized Business Records
(E)   Notarized Statements of hours worked from Benefit Funds
(F)   Social Security Records
      Must include License Number and where License is held.
(G)   Certified copies of licenses held

				
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