Additional Classification

COMPLETE THIS FORM TO ADD A CLASSIFICATION TO A CURRENT CERTIFICATE OF LICENSURE. THE FEE FOR EACH ADDITIONAL CLASSIFICATION IS $50.00. RETURN THE COMPLETED FORM WITH THE REQUIRED FEE TO MSBOC. FORMS OF PAYMENT ACCEPTED ARE MONEY ORDER, PERSONAL CHECK, CERTIFIED CHECK OR CASHIER’S CHECK. NO CASH ACCEPTED.

SECTION 1: IDENTIFYING INFORMATION

Number as it currently appears on certificate of licensure:

Name as it currently appears on certificate of licensure:

Name of person making request

First Last

Address to mail info, if testing required

Street Address Address Line 2 City State ZIP Code

Phone of person making request

Email of person making request

Enter Email Confirm Email

SECTION 2: CLASSIFICATION REQUESTED

THE FOLLOWING INFORMATION IS REQUIRED FOR EACH CLASSIFICATION TO BE ADDED TO A CURRENT CERTIFICATE OF LICENSURE. IF REQUESTING MORE THAN ONE CLASSIFICATION TO BE ADDED TO A CERTIFICATE OF LICENSURE, MAKE COPIES OF THIS FORM AND COMPLETE THE REQUESTED INFORMATION FOR EACH CLASSIFICATION YOU WISH TO ADD. FOR A COMPLETE LISTING OF CLASSIFICATIONS OFFERED VISIT WWW.MSBOC.US.

Classification(s) requested

First Option

Second Option

Third Option

Fourth Option

Fifth Option

SECTION 3: QUALIFYING PARTY INFORMATION AND EXPERIENCE

THE QUALIFYING PARTY IS THE INDIVIDUAL WHO TAKES THE REQUIRED EXAM(S). A LICENSE HOLDER MAY HAVE MULTIPLE QUALIFYING PARTIES AND/OR DIFFERENT QUALIFYING PARTIES FOR EACH EXAM. THE QUALIFYING PARTY WHO SITS FOR AN EXAM MUST BE AN OWNER, OFFICER, MEMBER OF THE EXECUTIVE STAFF, OR A RESPONSIBLE MANAGING EMPLOYEE. THE QUALIFYING PARTY MUST HAVE THE EXPERIENCE, KNOWLEDGE AND SKILLS TO SUPERVISE OR PERFORM THE WORK IN THE STATED CLASSIFICATION. THE LICENSE HOLDER MUST PROVIDE PROOF OF EMPLOYMENT OF THE QUALIFYING PARTY. ACCEPTABLE FORMS OF PROOF OF EMPLOYMENT INCLUDE A CHECK STUB OR W-2 FORM OR ARTICLES OF INCORPORATION LISTING THE INDIVIDUAL AS AN OFFICER. WHEN A QUALIFYING PARTY TERMINATES EMPLOYMENT WITH A LICENSE HOLDER, MSBOC MUST BE NOTIFIED IN WRITING IMMEDIATELY BY THE QUALIFYING PARTY AND THE LICENSE HOLDER. THE LICENSE HOLDER HAS NINETY (90) DAYS TO REPLACE A QUALIFYING PARTY. FAILURE TO NOTIFY MSBOC WHEN A QUALIFYING PARTY HAS LEFT MAY SUBJECT THE LICENSE HOLDER TO DISCIPLINARY ACTION.

Total due

Price: $0.00

Name

First Last

Social Security Number

Job Title

Is the individual a qualifying party currently associated with the certificate of licensure?

Yes

Proof of employment

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 256 MB.

Check stub, W-2 Form or Articles of Incorporation.

List projects completed by qualifying party listed above demonstrating experience in the classification requested.

Name of person making request/Title

First Last

Date

Signature of person making request

Additional Classification

SECTION 1: IDENTIFYING INFORMATION

SECTION 2: CLASSIFICATION REQUESTED

SECTION 3: QUALIFYING PARTY INFORMATION AND EXPERIENCE

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