Application for Registration as an Apprentice …

Attach a clear, full-facephotograph (2 x 2 )of your head andshoulders, taken within the past six photo is requiredwith each Application .(Do not use staplesto attach the photo.)State of New JerseyDEPARTMENT OF LAW AND PUBLIC SAFETYDIVISION OF CONSUMER AFFAIRSSTATE BOARD OF EXAMINERS OF MASTER PLUMBERS124 HALSEY STREET, 6TH FLOOR, BOX 45008 NEWARK, NEW JERSEY 07101(973) 504-6420 Application for Registration as an Apprentice Plumber(Pursuant to 45 and 45 )Please supply an address for each category below and indicate (by placing an X in the appropriate box) which of these should belisted as your address of record. If your mailing address is a post office box, you may choose to have correspondence directed to you therebut you may not use a post office box as your address of record. Your address of record must include a street address, city, state and ZIP : Your address of record is considered public information. It will be posted as part of the Online Licensee Directories at If you fail to designate an address of record, your home address will be considered your address print or InformationLast nameFirst nameMiddle initialMaiden name (if applicable) Home AddressStreetCityStateZIP codeCountyTelephone number (include area code)E-mail address Business AddressName of companyTelephone number (include area code)StreetCityStateZIP codeCounty Mailing AddressStreet or BoxCityStateZIP codeCountyPlease indicate the address to which co

6. Statement of employment in conjunction with the Apprenticeship Program. Give a detailed account of your current employment in the business of plumbing, giving the dates, the employer’s name, and your

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