App. Rec’d-----------------
Review committee decision-----------Date--------
Appeal review
Review Executive Board of NJPIA
decision-----------Date--------
Plumbing Inspectors Association Incorporated
NJPIA Legal Fund Application
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Office use only App. Rec’d----------------- Review committee decision-----------Date-------- Appeal review Review Executive Board of NJPIA decision-----------Date-------- |
Please print
Full name___________________________________________Date of Birth_____________
Address____________________________________________________________________
Phone (Home)________________________________________Business ________________
Business address_____________________________________________________________
Position__________________________________Full Time_________Part Time________
Civil Service______________Non Civil Srevice_______________Tenure____________
License (s) now hold Please submit evidence of the following information
Issued by the Department of Community Affairs
Plumbing Inspector /I.C.S. No.______________Date____________
H.H.S. No.______________Date____________
Plumbing Sub Code Official No.______________Date____________
Construction Official No.___________________Date____________
Other licenses held No._____________________Date____________
No._____________________Date____________
Statement: Reason for funding legal representation.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________