Maryland Plumbing-Heating-Cooling Contractors, Inc. Suite 205, 10176 Baltimore National Pike Ellicott City, MD 21042-3652 (410) 461-5977 ** Fax (410) 750-2507 e-mail: phccmd@aol.com INSTRUCTOR APPLICATION – PLUMBING APPRENTICESHIP PROGRAM
NAME______________________________________ ___SOCIAL SECURITY NO.________________ HOME ADDRESS______________________________________________________________________ CITY__________________________________STATE_______________ZIP CODE________________ HOME PHONE (
)____________________WORK PHONE (
)__________________________
OCCUPATION___________________________________EMPLOYER__________________________ MARYLAND LICENSE PLUMBER (CIRCLE ONE)
YES
NO
IF YES (CHECK CATEGORY) _______MASTER ______JOURNEY _______INSPECTOR______ MARYLAND STATE LICENSE NO._______WSSC LICENSE NO_________BALTO CO_________ DID YOU ATTEND AN APPRENTICESHIP SCHOOL? (CIRCLE ONE)
YES
NO
IF YES, NAME OF SCHOOL____________________________________________________________ DID YOU GRADUATE? (CIRCLE ONE)
YES
NO
IF YES, WHAT YEAR_____________
WORK EXPERIENCE: CHECK WHERE APPLICABLE:
_____RESIDENTIAL _____INDUSTRIAL _____COMMERCIAL _____SERVICE _____NEW____
LIST OTHER LICENSES AND/OR CERTIFICATIONS HELD:
ARE YOU SELF EMPLOYED? (CIRCLE ONE)
YES
NO
IF YES, TYPE OF BUSINESS____________________________________________________________ LOCATION OF BUSINESS? ____________________________________________________________ COUNTY STATE