Plumber License Application/affidavit Form - West Virginia Division Of Labor printable pdf download

WEST VIRGINIA DIVISION OF LABOR

State Capitol Complex - Building 6, Room B-749 - Charleston, WV 25305

Telephone: (304) 558-7890

Facsimile: (304) 558-5174

Plumber License Application/Affidavit

General Information:

(Please Print)

Name: ________________________________________ Phone #: ____________________________

First

Middle Initial

Last

Social Security Number: ____________________________ Date of Birth: _____________________

Mailing Address: ___________________________________________________________________

City: __________________________ State: __________ Zip: __________ County: ______________

Have you ever been certified as a plumber in WV? Yes

If yes, License #:___________

Type of License:

(Please mark appropriate classification for which you are applying)

Master Plumber

(I certify I have at least twelve thousand hours (12,000) of plumbing experience)

Journeyman Plumber

(I certify I have at least eight thousand hours (8,000) of plumbing experience)

Plumber in Training

(I understand I am required to work under the direct supervision of a licensed

Master or Journeyman Plumber when performing plumbing work)

(No Examination Required)

Examination:

A Master or Journeyman Applicant is required to submit their examination score report with this

application/affidavit.

__________________________

(Date of Examination)

(Score)

Fee: Master - $75.00

Journeyman - $75.00

Plumber in Training - $50.00

Please attach a check, certified check, cashier’s check or money order made payable to the West Virginia

Division of Labor,

NO CASH PLEASE.

PRIVACY NOTICE

The Division of Labor processes your personal information for appropriate and customary business purposes. Your personal information may be

disclosed to other State agencies or third parties in the normal course of business as needed to comply with State or Federal laws. If you have any

questions about the Division of Labor's use of your personal information or would like a copy of the Division's complete privacy notice, please contact

Robert Bryant at Robert.L.Bryant@wv.gov.

The undersigned hereby certifies under penalty of perjury that information provided on this application/affidavit is true to the best of my knowledge and

belief and that I realize that making a false statement may result in loss of my license.

Signature: ___________________________________________

Date: _________________________

(Applicant’s Signature)

Subscribed and sworn to before me, the undersigned Notary Public this _____ day of ________________,

20 _____. My commission expires _______________________.

____________________________

Notary Public