Fill and Sign the 2014 Form W 2gu Guam Wage and Tax Statement

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF LABOR AND TRAINING DIVISION OF PROFESSIONAL REGULATION PIPEFITTERS, REFRIGERATION TECHNICIANS, SHEET METAL, AND FIRE PROTECTION SPRINKLER FITTER APPLICATION *** INSTRUCTIONS – PLEASE READ CAREFULLY *** APPLICATIONS WILL NOT BE REVIEWED BY THE DEPARTMENT OF LABOR AND TRAINING IF THE FOLLOWING DIRECTIONS ARE NOT ADHERED TO 1) TWO (2) HEAD AND SHOULDERS PHOTOGRAPHS (PASSPORT TYPE), MUST BE SUBMITTED WITH APPLICATION. 2) YOUR APPLICATION MUST BE SIGNED AND NOTARIZED. 3) APPLICATION FEE OF $75.00 IS REQUIRED TO PROCESS YOUR APPLICATION. THIS IS A NON-REFUNDABLE APPLICATION FEE. CHECK SHOULD BE MADE PAYABLE TO THE GENERAL TREASURY/STATE OF RHODE ISLAND. 4) UNDER WORK EXPERIENCE – A SEPARATE, DETAILED, NOTARIZED STATEMENT, ON COMPANY LETTERHEAD, OF ALL WORK RELATED EXPERIENCE, AND OTHER INFORMATION SHOULD BE ATTACHED TO THIS APPLICATION. *** PLEASE DETAIL YOUR WORK EXPERIENCE THOROUGHLY *** 5) All Pipefitter, Refrigeration Technician, Sheet Metal Worker Journeypersons, and Sprinklerfitter Journeypersons Tests require the completion of a State of Rhode Island approved apprenticeship program. An out-of-state license in the above mentioned trades will allow the holder of the license to be tested in the trade in which the license is held. 6) Reference for our tests are from the following, but not limited to: A) International Mechanical Code Book, Year 2003-Latest State approved Edition. (AVAILABLE: 1 CAPITOL HILL, PROVIDENCE, RI 222-3032) B) REFRIGERATION & AIR CONDITIONING TECHNOLOGY, 4th Ed. (ISBN#0-7668-0667-7 Delmar Book) C) PUBLICATIONS AND ADDRESSES: SMACNA – 4201 Lafayette Center Dr., Chantilly, VA 02151 HVAC Duct Construction Standards, Metal & Flexible, 2nd Ed. Author: Sheet Metal & A/C Contractors National Association Inc. Publisher: SMACNA ISBN: 1481 OSHA – 4025 WEST PETERSON AVENUE, CHICAGO, IL 60646 Welding Principals & Applications - 3 Columbus Circle, Box 15-015 Albany, NY 12212 State Building Codes - 1 Capitol Hill, Providence RI 02908 D) GENERAL TRADE KNOWLEDGE. 1. STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF LABOR AND TRAINING DIVISION OF PROFESSIONAL REGULATION 1511 PONTIAC AVENUE – BUILDING 70 P.O. BOX 20247 CRANSTON, RHODE ISLAND 02920-0943 (401)462-8580 FAX (401)462-8528 TDD (401)462-8006 www.dlt.state.ri.us * PIPEFITTERS * SHEET METAL * FIRE PROTECTION SPRINKLER FITTER * REFRIGERATION *** APPLICATION FOR EXAMINATION AND APPRENTICE CARD *** APPLICATION MUST BE CLEARLY PRINTED SOCIAL SECURITY NUMBER LAST NAME FIRST NAME MI STREET ADDRESS CITY/TOWN STATE ZIP TELEPHONE DATE OF BIRTH EMPLOYER SELF-EMPLOYED/COMPANY NAME STREET ADDRESS CITY/TOWN STATE ZIP EMPLOYER TELEPHONE CATEGORY – APPLICANTS MUST STATE WHAT LICENSE IS REQUESTED LICENSE NUMBER ISSUED BY THIS DIVISION – OR COPY OF YOUR OUT-OF-STATE LICENSE IS REQUIRED. (IF APPLICABLE) FOR OFFICE USE ONLY – PLEASE DO NOT WRITE BELOW TEST FEE PAID, CHECK, CASH, M.O. DIVISION/COMMISSION APPROVAL FOR TEST $ ____________________________________ ________________________________________________ COMMENTS ______________________________________ DATE PAID ________________________________________________ 2 Applicant must answer all questions on both pages truthfully and swear to the same before a NOTARY PUBLIC, penalties for false information are as itemized in the General Laws of Rhode Island and Addendum. Statement may be investigated and verified for truthfulness. GENERAL LISTING OF WORK HISTORY NAME OF EMPLOYER FROM/TO TYPE OF WORK ____________________ __________________ __________________ ________________________ _____________________ _____________________ ________________________ _____________________ _____________________ EDUCATION List all education and schooling that you have received in the refrigeration, air conditioning, heating, pipefitting, sprinklerfitter, and sheet metal trade. LOCATION FROM/TO DEGREE/DIPLOMA ____________________ __________________ __________________ ________________________ _____________________ _____________________ ________________________ _____________________ _____________________ YOU MUST LIST ANY VALID LICENSE YOU NOW HOLD WITH THIS DIVISION AND A COPY OF YOUR OUT-OF-STATE LICENSES. ________________________ TYPE OF LICENSE _____________________ TYPE OF LICENSE _____________________ TYPE OF LICENSE Listed employer or customer may be sent forms to attest to the truthfulness of all statements on this application and these will have to be sent back to this division, properly notarized, before any action is taken on this licensing test application. _______________________________ APPLICANT’S SIGNATURE __________________ DATE ____________________________ Notary Signature, Seal and Expiration Date FOR OFFICE USE ONLY APPROVAL/AUTHORIZATION If you fail to pass your examination, you may request a review of the same, in writing, to the Division of Professional Regulation, within thirty (30) days of failure notice. 3 NON-REFUNDABLE PROCESSING APPLICATION FEE COMPUTER CODE MECHANICAL TEST FEE RENEWAL & LICENSE FEE 001 MMA Contractor Master Pipefitter Refrigeration Sheet Metal NO TEST $ 240 096 097 098 Master Mechanical Contractor $ $ $ $ 75 75 75 75 $ 120 $ 120 $ 120 $ 120 Refrigeration MASTER 1 RM1 002 $ 75 $ 120 Refrigeration MASTER 2 RM2 003 $ 75 $ 48 Pipefitter MASTER 1 PM1 004 $ 75 $ 120 Pipefitter MASTER 2 PM2 005 $ 75 $ 48 Sheet Metal Master I SMM 1 040 $ 75 $ 120 Sheet Metal Master II SMM 2 042 $ 75 $ 48 PJF/ NATURAL GAS SERVICE MASTER II LTD 044 $ 75 $ 120 PJF/ Gas Serviceman (Propane Gas) Master II LTD 048 $ 75 $ 120 Refrigeration JOURNEYMAN 1 RJ1 006 $ 75 $ 36 Refrigeration JOURNEYMAN 2 RJ2 007 $ 75 $ 30 Pipefitter JOURNEYMAN 1 PJ1 008 $ 75 $ 36 Pipefitter JOURNEYMAN 2 PJ2 009 $ 75 $ 30 Sheet Metal Journeyperson I SMJ 1 041 $ 75 $ 36 Sheet Metal Journeyperson II SMJ 2 043 $ 75 $ 30 Fire Suppression LTD LIMITED 010 $ 75 $ 30 Decorative Heating Appliances LTD LIMITED 045 $ 75 $ 30 Welding LTD LIMITED 012 $ 75 $ 30 Gas Serviceman (Natural Gas) PJF LIMITED 019 $ 75 $ 72 Gas Serviceman (Propane Gas) JOURNEYMAN 2 PJF LIMITED 013 $ 75 $ 72 O/B Serviceman JOURNEYMAN 2 PJF LIMITED 015 $ 75 $ 72 Gas Station LTD LIMITED 016 $ 75 $ 30 Synthetic Exhaust Ducting LTD LIMITED 046 $ 75 $ 30 Fire Protection Master FPM 017 $ 75 $ 120 Fire Protection Journeyman FPJ 018 $ 75 $ 36 4