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Hamilton County

Application for License 4005 Cromwell Road Chattanooga, TN 37421 Phone ? (423) 209-7860 / Fax ? (423) 209-7861

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I AM APPLYING FOR (Check One)

Office Use only

Date Rec'd _______ Amt Rec'd _______ Type of Payment

Cash M.O. CK CR

Lic Issued _______ Test results ______ Notes:

Class I Electrical Contractor (unrestricted) Class I State Electrical Contractor (unrestricted) Class II Electrical Contractor (restricted) Class III Electrical Contractor (signs only) Class IV Journeyman Class IV Journeyman (by State License) Class V Electrical Contractor (special) Class I State Plumbers License

$100.00 $50.00 $100.00 $50.00 $10.00 $5.00 $100.00 $100.00

Class I Master Plumber

$100.00

Class III Journeyman Plumbers License

$10.00

Class III Journeyman Plumbers License (by State License) $10.00

Class I HVAC ? Mechanical Contractor (unrestricted) $100.00

Journeyman's Mechanical License

$20.00

Master Gas Contractor's License

$100.00

Journeyman's Gas License

$10.00

Class II Mechanical License

$100.00

Please Type or Print

Name:

________________________________________________________________________

Mailing Address: ________________________________________________________________________

City: _________________________________________ State: ___________ Zip: ____________________

Date of Birth: ______/______/______

Social Security #: _________-_________-__________

Home Telephone Number: _______________________________

Company Name: ________________________________________________________________________

Business Address: ________________________________________________________________________

City: _________________________________________ State: ___________ Zip: ____________________

Business Phone: ______________________ Fax Number:

________________________

Pager Number:

______________________ Mobile Number: ________________________

E-Mail Address: ______________________ Internet Address: ________________________

Education and Training The highest grade I completed was _________________. Trade school or apprentice school training: Did you attend a trade or apprentice school? Yes No

If yes, did you complete the full course? Yes No

List other license that you have held or currently hold including Plumbing, Gas, Building, Electrical and Mechanical:

_____________________________/__________________/_________________/____________________________________

Type & Licenses Number

Issue Date

Expiration Date

Agency that issued the license

_____________________________/__________________/_________________/____________________________________

Type & Licenses Number

Issue Date

Expiration Date

Agency that issued the license

_____________________________/__________________/_________________/____________________________________

Type & Licenses Number

Issue Date

Expiration Date

Agency that issued the license

EMPLOYMENT RECORD: List previous employers where you have worked in the last three (3) years prior to this date:

1. Present Employer: ________________________________________________________________________________

___________________________________________________________________________________________________

Street Address

City

State

Zip Code

I have been employed here for ______ year(s).

Job Title: _____________________________________

Duties: ____________________________________________________________________________________________

___________________________________________________________________________________________________

2. Employer: ______________________________________________________________________________________

___________________________________________________________________________________________________

Street Address

City

State

Zip Code

I was employed there for ______ year(s).

From ___________________ To__________________

Job Title: __________________________________________ Duties: __________________________________________

___________________________________________________________________________________________________

3. Employer: ______________________________________________________________________________________

___________________________________________________________________________________________________

Street Address

City

State

Zip Code

I was employed there for ______ year(s).

From ___________________ To__________________

Job Title: __________________________________________ Duties: __________________________________________

___________________________________________________________________________________________________ The Board reserves the right to correspond with any employers listed above and to check all information given in the application.

I the undersigned, affirm that all the above statements are true and correct and any false statement herein will be just cause for failing to grant my license or to revoke it at any time, in the future. I will abide by the ordinances, codes and requirements of the County of Hamilton, Chattanooga, Tennessee in using my license. No refund on license, examination or renewal fees shall be given.

__________________ Date

____________________________________________________ Applicants Signature

Sworn before me this __________day of the year __________.

My appointment expires __________________

_______________________________________________ Notary Public

(seal) Return this completed signed application form to the address on the heading together with a check, money order or cash (do not mail cash) for the examination fee or license fee applied for. Make all checks payable to : Hamilton County Trustee.

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