Plumbing: Work Experience Verification Form

Minnesota Department of Labor & Industry
Construction Codes and Licensing Division

Licensing and Certification Services
443 Lafayette Road North
St. Paul, MN 55155
Mailing Address:
PO Box 64217
St. Paul, MN 55164-0217
PLUMBING
Phone: 651.284.5031 Work Experience Verification Form
Email: [email protected]
Web site: www.dli.mn.gov
PRINT clearly IN INK OR TYPE
M AKE A COPY OF THIS FORM FOR YOUR RECORDS
Applicant’s Legal Name: License / Registration Number: (if applicable) SSN: (Last 4 digits Only)
Applicant’s Address: City, State, Zip Email Address:
To renew a registration, unlicensed individuals must provide verification of their employment by a licensed contractor or registered employer
for the registration period. Verification information required includes: name, address, and phone number of the employer, registered
individual’s dates of employment with the employer, class of work performed; and hours worked. The information provided on this form is
public data and shall be used to qualify the registered unlicensed individual for an applicable license exam. Individuals with multiple
employers during the reporting period must make copies of the form and have each employer complete a separate verification.
Employer Name License / Registration Number
Employer Address Telephone
City State Zip Email Address
Name of Responsible Person (Master Plumber) License Number Title
Qualifying work experience is verified based on a 12-month registration period of July 1 to June 30. Actual hours must be reported by
Class of Work performed by the registered individual. Blanks will be recorded as 0 hours. No more than a total of 1,750 qualifying hours
may be reported per 12-month registration period. Hours reported on this form must be supported by records maintained by the employer
for demonstrating compliance. Knowingly providing inaccurate or fraudulent information may constitute a violation and subject the violator
to a civil penalty of up to $10,000.
Complete a SEPARATE work experience form for each year of employment. Are the hours reported on this form
taken from payroll records?
Date of Employment:
Start Date: End Date:
YES OTHER (specify)
July 1
CLASS OF WORK For Office Hours Worked
Use Only
DRAIN, WASTE, AND VENT INSTALLATION DW
FIXTURE INSTALLATION FI
MAINTENANCE AND REPAIR OF PLUMBING MR
WATER DISTRIBUTION INSTALLATION WD
WATER SERVICE AND SEWER INSTALLATION WS
TOTAL OF ALL QUALIFYING HOURS WORKED (MAX 1,750 HOURS PER YEAR)
Form must be signed by the designated Responsible Person and Applicant. I certify that I personally know or that the employer’s
employment records verify that this individual, during the referenced employment period, engaged in the identified classes of work for
the number of hours shown. The applicant's signature below acknowledges agreement with the information provided on this form.
RESPONSIBLE PERSON’S SIGNATURE DATE SIGNED APPLICANT'S SIGNATURE DATE SIGNED
This material can be made available in different forms, such as large print, braille or on audio. CC0100 Plumbing Work Experience Form
INSTRUCTIONS
READ CAREFULLY BEFORE COMPLETING THIS FORM
Employer must complete the Work Experience Verification Form
WORK EXPERIENCE VERIFICATION FORM REQUIRED

Registered unlicensed individuals, as part of renewing their registration, must provide verification of their employment by a licensed
contractor or registered employer during the registration period of July 1 to June 30. This form reports the verified hours and is adapted
for use by unlicensed individuals registered to perform plumbing work. The reason for verifying work hours each year along with renewing
a registration is so the registered individual does not have to verify these hours when applying for a license examination. Verifying hours
annually when renewing a registration enables the department to gradually qualify an individual for examination, which makes for quicker
approvals. Please submit a separate work experience form for each year of experience.
Employer Information (mandatory information if business is licensed in Minnesota)

• Enter the employer’s business name, address, license or registration number, contact’s phone number, and email address.
(NOTE: License number is mandatory, if business holds contractor license number or registered employer number in Minnesota.)
• Enter the employer’s designated responsible individual’s name and license number. The individual’s license number must match
what the department has on record as the designated responsible individual and license number.
• Only record work experience for the time period that the registered unlicensed plumber had a current registration with Department
of Labor Industry.
•
Registered Apprentice - If part of an apprenticeship program the following is required when applying for the journey worker exam:
• Complete exam application.
• Letter from apprenticeship program, which includes hours, dates of completion and name of the apprenticeship program.
Note: Up to 24 months of practical plumbing experience prior to becoming a plumber's apprentice or registered unlicensed individual may be
applied to the four-year experience requirement. However, none of this practical plumbing experience may be applied if the individual did not
have any practical plumbing experience in the 12-month period immediately prior to becoming a plumber's apprentice or registered unlicensed
individual.
Unlicensed Registered Plumber

• Complete information on the form for the registered individual.
• The work period being verified is the 12-month registration period of July 1st to June 30th of each year and only for the months in
which you had a current registration with Department of Labor & Industry.
• Provide exact dates of employment during the 12-month registration period (July 1st to June 30th). Include the month, day, and year.
• Indicate whether the hours reported on the form are taken from payroll records; and if not, specify the other forms of documentation
used to verify the individual’s work experience.
• For each class of work identified, enter the actual hours the individual performed that class of work during the registration period.
(Note: Blanks will be assigned 0 hours.)
• Enter the total number of plumbing work hours verified, which may not exceed 1,750 hours.
• Complete mailing address information for the unlicensed individual’s. Updates to the individual’s personal or mailing address may
be noted on the registration renewal form. Address changes may also be made using a form available online at
http://www.dli.mn.gov/workers/plumber/licensing-personal-plumber-licenses.
Certification Signature and Date

• The employer’s designated responsible individual must certify, with a signature, that the registered unlicensed individual performed
the identified classes of work for the number of hours entered on the form during the 12-month registration period.
• The registered unlicensed individual’s signature on the form acknowledges agreement with the information verified by the employer.
QUALIFYING FOR A LICENSE EXAMINATION

Work verification is for the following license classifications, which require a minimum number of months/hours qualifying work
experience to become licensed. Detailed information on qualifying for a license exam is available at www.dli.mn.gov
License Class Law (Rule) Requirement Minimum Requirements
Plumber Journey Worker 326b.46 Law 7,000 hours 2000 hours drain, waste, vent installation
4716.0020 Rule 1000 hours fixture installation
2000 hours water distribution installation
Plumber Master 326B.46 Law 1, 750 hours Must have at least one year of practical plumbing experience as a licensed
4716.0020 Rule journey worker plumber; or
A current master plumber license from another state where the

requirements of the licensing jurisdiction are equivalent to those of
Minnesota, as determined by the commissioner; or
A current Minnesota restricted master plumber license and five years of

verifiable experience in business as a plumbing contractor in Minnesota.
CC0100 Plumbing Exam Work Experience

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Minnesota Department of Labor & Industry

Construction Codes and Licensing Division

Applicant’s Address: City, State, Zip Email Address:

Employer Name License / Registration Number

Employer Address Telephone

City State Zip Email Address

Name of Responsible Person (Master Plumber) License Number Title

MAINTENANCE AND REPAIR OF PLUMBING MR

WATER DISTRIBUTION INSTALLATION WD

WATER SERVICE AND SEWER INSTALLATION WS

WORK EXPERIENCE VERIFICATION FORM REQUIRED

Employer Information (mandatory information if business is licensed in Minnesota)

Unlicensed Registered Plumber

Certification Signature and Date

QUALIFYING FOR A LICENSE EXAMINATION

A current master plumber license from another state where the

A current Minnesota restricted master plumber license and five years of

CC0100 Plumbing Exam Work Experience

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