Office Use Only: CORI sent _________  CORI rec’d: ________Ck.# _______Appl.# _______ Lic.# _______ Init.______

BOARD OF EXAMINERS OF SHEET METAL WORKERS
APPRENTICE SHEET METAL WORKER
LICENSE APPLICATION

1) Application Date: ___ ___ - ___ ___ - ___ ___ ___ ___

2) Applicant’s Full Name:
______________________________________________________________________________
Last Name
First Name
Middle Name
Suffix

3) Maiden Name, Former Name, Also Known As:
______________________________________________________________________________
Other Last Name
Other First Name
Other Middle Name

4) Gender : Male ___ Female ___ Prefer Not to Answer ___

5) Date of Birth : ___ ___ - ___ ___ - ___ ___ ___ ___

6) Mailing Address:
No.

City/Town

Street

Apt. #

State

Zip Code

7) E-mail Address: _______________________________________________________________
Please note: EMAIL is the primary means of contact for routine correspondences during the application process.

8) Preferred Communication: Email ___ Mail ___

9) Telephone :

Primary ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ Ext. ___ ___ ___ ___
Mobile ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Other

___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ Ext. ___ ___ ___ ___

10) Fax :

Fax No. ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___ Ext. ___ ___ ___ ___

11) Have you completed training from a Board approved sheet metal program or Board approved vocational school? If yes, please complete questions # 12 and # 13.
Yes:
No:

12) Name of school or training program: ____________________________________________

13) Years Attended: _____________________________________________________________

14) Name of Employing Master Sheet Metal Worker:
______________________________________________________________________________
Last Name
First Name
Middle Name
Suffix
Master Sheet Metal Worker License No. _____________________

15) List all professional licenses/certifications you have held in the United States, or any country or jurisdiction, and the state/jurisdiction from which the license/certification was originally issued.
____________________________________________________________________________________

16) Has any disciplinary action been taken against you by a licensing/certification board located in the
United States or any country or foreign jurisdiction?
Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
____________________________________________________________________________________

17) Are you the subject of pending disciplinary actions by a licensing/certification board located in the
United States or any country or foreign jurisdiction?
Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
____________________________________________________________________________________

18) Have you ever voluntarily surrendered or resigned a professional license to a licensing/certification board in the United States or any country or foreign jurisdiction?
Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
____________________________________________________________________________________

19) Have you ever applied for and been denied a professional license in the United States or any country or foreign jurisdiction?
Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
____________________________________________________________________________________
20) Have you ever been convicted of, or admitted to, a felony or misdemeanor in the United States or any country or foreign jurisdiction?
Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
____________________________________________________________________________________
21) Have you ever been charged with a criminal violation which led to a disposition of “continued without a finding”(“CWOF”) or admission to sufficient facts?
Yes:
No:
If yes, please state the details (use a separate sheet if necessary):
____________________________________________________________________________________

I certify, under the pains and penalties of perjury, that the information I have provided pursuant to this application for licensure is truthful and accurate. I understand that the failure to provide accurate information may be grounds for the Massachusetts Board of Examiners of Sheet Metal Workers to deny me the right to as a candidate or to suspend or revoke a license issued to me in accordance with
Massachusetts Law. I further attest that, pursuant to G.L. c.62C, §49A, to the best of my knowledge and belief, I have filed all Massachusetts tax returns and paid all Massachusetts taxes required by law.

Signature of applicant

Date of Birth (mm/dd/yyyy)

Date

STATEMENT OF THE EMPLOYING MASTER SHEET METAL WORKER:
I ___________________________________________________________________ ________________
(Please Print Name of Employing Master Sheet Metal Worker)

(License Number)

Operating a Sheet Metal Company under the business firm name of
_____________________________________________________________________________________
Located at:
_____________________________________________________________________________________
(Address)

(City/Town)

(State)

(Zip Code)

Telephone Number: ______- _______- ____________ do hereby make application to register
_______________________________________________________________ as an apprentice sheet
(Please Print Name of Apprentice Applicant)

metal worker. I herby certify that the apprentice will be employed by me and will work under the direct supervision of a journeyman sheet metal worker in my employ in accordance with the provisions of
271 CMR 5.02 (2). I have verified that all of my employees possess a current license in good standing with the Board of Examiners. I herby certify that the previous statements are true and are made under the pains and penalties of perjury.

Signature of Employing Master Sheet Metal Worker:
_____________________________________________________________________________________

YOU MUST INCLUDE THIS

APPLICATION CHECKLIST
WITH YOUR APPLICATION

□
□
□
□
□

I have included a 2” x 2” color passport photo
I have included certificates of completion for any Board approved Training (if applicable)
I have included the “Statement of Employing Master” form
I have included the “CORI Authorization Form”
I have included the $ 65.00 non-refundable application / license fee payable to the
“Commonwealth of Massachusetts”

MANDATORY
My social security number is:

□□□-□□-□□□□
Pursuant to G.L. c. 62C, § 47A, the Division of Professional Licensure is required to obtain your social security number and forward it to the Department of Revenue. The Department of Revenue will use your social security number to ascertain whether you are in compliance with the tax laws of the
Commonwealth.

Signature of applicant

Date of Birth (mm/dd/yyyy)

Date

Mail your application materials to:
DPL - Board of Sheet Metal, 1000 Washington Street – Suite 710, Boston, MA, 02118-6100.

Revised 3/4/15

Office Use Only: CORI sent _________  CORI rec’d: ________Ck.# _______Appl.# _______ Lic.# _______ Init.______

CRIMINAL OFFENDER RECORD INFORMATION (CORI)
ACKNOWLEDGEMENT FORM
The Division of Professional Licensure by itself and on behalf of boards of registration pursuant to
M.G.L. c. 13, §9 [hereinafter, “Division of Professional Licensure”] is registered under the provisions of
M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective license applicants and current licensees.
As a license applicant or current licensee, I understand that a CORI check will be submitted for my personal information to the Department of Criminal Justice Information Services (“DCJIS”). I hereby acknowledge and provide permission to the Division of Professional Licensure to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing the Division of Professional Licensure written notice of my intent to withdraw consent to a CORI check.
FOR LICENSING PURPOSES ONLY:
The Division of Professional Licensure may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that the Division of Professional Licensure must first provide me with written notice of this check.
By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2 of this Acknowledgement Form is true and accurate.

_________________________________
Signature

_________________________________
Date

NOTE: DPL CANNOT ACCEPT THIS TWO-PAGE CORI ACKNOWLEDGMENT FORM UNLESS
IT IS EITHER (1) SIGNED IN PERSON AT THE BOARD'S OFFICES IN THE PRESENCE OF A DPL
EMPLOYEE WHO HAS VERIFIED THE APPLICANT'S IDENTITY THROUGH ACCEPTABLE
IDENTIFICATION, OR (2) SIGNED IN THE PRESENCE OF A NOTARY PUBLIC WHO HAS
LIKEWISE VERIFIED IDENTITY AND THEN MAILED OR OTHERWISE DELIVERED TO THE
BOARD'S OFFICES AT THE ADDRESS SET FORTH ABOVE.

SUBJECT INFORMATION: (A red asterisk (*) denotes a required field)
_____________________________________________________________________________________
*Last Name
*First Name
Middle Name
Suffix
_____________________________________________________________________________________
*Maiden Name (or other name(s) by which you have been known)
___________________
*Date of Birth

____________________________
Place of Birth

*Last Six Digits of Your Social Security Number: ________ - ___________
Sex: ______

Height: ____ ft. ____ in.

Eye Color: _________

Driver’s License or ID Number: ___________________

State of Issue: ___________________

Current and Former Addresses:
_____________________________________________________________________________________
Street Number & Name
City/Town
State
Zip
_____________________________________________________________________________________
Street Number & Name
City/Town
State
Zip
_____________________________________________________________________________________

IDENTITY VERIFICATION SECTION: If this form is submitted by hand at DPL
Offices, Section A must be completed. Otherwise, Section B must be completed.
SECTION A: VERIFICATION BY DPL EMPLOYEE: I hereby certify that I verified the identity of the abovereferenced subject by reviewing the following form(s) of government-issued identification:1
 Passport  State Issued driver’s license
 Military identification  State-issued identification card
VERIFIED BY: ________________________________________________________________________________
Name of Verifying DPL Employee (Please Print)
________________________________________________________________________________
Signature of Verifying DPL Employee
Date

_____________________________________________________________________________________________
SECTION B: VERIFICATION BY NOTARY:
On this ______ day of _____________, 20____, before me, the undersigned notary public, personally appeared
_________________________________ (name of document signer), and proved to me through satisfactory evidence of
†
identification, which was the following:
 Passport  State-issued driver’s license  Military identification  State-issued identification card to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.
_____________________________________________________________________________________________
Notary Public:
Notary Commission Expires On

1

If a subject does not have an acceptable government-issued identification, his or her identity shall be verified by other forms of documentation as determined by DCJIS. 803 CMR 2.09(2).