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
EMPLOYER: LIST OF EMPLOYERS OVER LAST 10 YEARS
DO YOU HAVE ANY TEACHING EXPERIENCE? (CIRCLE ONE)
YES
NO
IF YES, WHERE WERE YOU EMPLOYED AS AN INSTRUCTOR? _________________________ NAME OF SCHOOL HOW LONG?______________________________WHAT YEAR DID YOU TEACH? ______________________
DID YOU TEACH TRADE MATH? (CIRCLE ONE)
YES
NO
CAN YOU TEACH TRADE MATH? (CIRCLE ONE)
YES
NO
WHICH YEAR WOULD YOU PREFER TO TEACH? MARK CHOICE BELOW:
_____FIRST YEAR _____SECOND YEAR _____THIRD YEAR _____FOURTH YEAR
_____NO PREFERENCE
WHICH LOCATION WOULD YOU PREFER? MARK CHOICE:
_____
ANNE ARUNDEL COUNTY – CENTER OF APPLIED TECHNOLOGY, NORTH 800 Stevenson Road, Severn, MD Classes are held on Monday & Wednesday Evenings – 6:00 p.m. - 9:00 p.m.
_____
ESSEX COMMUNTIY COLLEGE 7201 Rossville Blvd., Baltimore, MD Classes are held on Tuesday & Thursday Evenings – 6:00 P.M. – 9:00 P.M.
Will you be available to start in September, 2013? (Circle one)
YES
NO
Signature of Applicant_______________________________________Date_________________