02_TL_1.6.12_HVAC_Qualifier.pdf

#3122 (Rev. 2/16)

Class Code 7642 Page i Committed to Equal Opportunity in Employment and Licensing

Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 78780 Office Location: 1400 E. Washington Avenue Milwaukee, WI 53293-0780 Madison, WI 53703 FAX #: (608) 267-0592 E-Mail: DSPSCredTrades@wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov

DIVISION OF PROFESSIONAL CREDENTIALING PROCESSING

INSTRUCTIONS FOR HVAC QUALIFIER APPLICATION

Requirements for Credential

Per Wis. Admin. Code § SPS 305.71, an individual may obtain in accordance with this section an HVAC Qualifier certification from the

Department relative to the business of installing or servicing heating, ventilating or air conditioning equipment. A person or entity who utilizes a person who holds an HVAC Qualifier certification under this section shall be deemed to be a certified HVAC business and pursuant to Wis. Stats. § 101.178(3)(c) may not be required to obtain a local certification, license or other approval in order to engage in the business of installing or servicing heating, ventilating or air conditioning equipment.

AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:

1. Application and Fee: The fee consists of a $15 application fee and a $25 exam fee. When the exam is passed the applicant will pay a $60 credential fee, based on a 4 year term from the date of issuance.

2. Experience/Education: A person applying for an HVCA Qualifier certification examination shall have completed one of the following

a. Experience: At least 1,000 hours per year for at least 4 years of experience in supervising or performing the design, installation, servicing or maintenance of HVAC systems or equipment. Complete the Experience Table on Page 2.

b. Education: At least 4 years of attendance in a school of mechanical engineering or in an accredited college, university, or technical, vocational or apprenticeship school in an HVAC related program. Attach a copy of transcripts.

c. Experience and Education: Any combination of 4 years of experience and education listed above.

3. Examination: Select an exam date on Page 2. For additional information on exam content, please view the Department website at http://dsps.wi.gov under “Licenses, Permits, and Registrations” and select “Trades Professions.”

mailto:DSPSCredTrades@wi.gov http://dsps.wi.gov/ https://docs.legis.wisconsin.gov/code/admin_code/sps/safety_and_buildings_and_environment/301_319/305/VII/71 http://docs.legis.wisconsin.gov/statutes/statutes/101/I/178

Class Code 7642 Page 1 of 3 Committed to Equal Opportunity in Employment and Licensing

Wisconsin Department of Safety and Professional Services

Mail To: P.O. Box 78780 Office Location: 1400 E. Washington Avenue Milwaukee, WI 53293-0780 Madison, WI 53703 FAX #: (608) 267-0592 E-Mail: DSPSCredTrades@wi.gov Phone #: (608) 266-2112 Website: http://dsps.wi.gov

DIVISION OF PROFESSIONAL CREDENTIALING PROCESSING

APPLICATION FOR HVAC QUALIFIER CERTIFICATION

Under Wisconsin law, the Department must deny your application if you are liable for delinquent State Taxes or Child Support (Wis. Stats. § 440.12).

PLEASE TYPE OR

PRINT IN INK

Your name and address are available to the public. Check box to withhold street address/PO Box number from lists of 10 or more credential holders (Wis. Stat. § 440.14).

Last Name First Name MI Date of Birth

Address (street, city, state, zip) Daytime Telephone Number

Social Security #

Your Social Security Number must be submitted with your application on this form. If you do not have a

Social Security Number, you must complete Form #1051. The Department may not disclose the Social

Security Number collected except as authorized by law.

Have you ever held a Trades credential in WI? Yes No If yes, list your credential number:

Email Address

APPLICATION FEES: Please check applicable box. Make check payable to DSPS and attach to this application.

I am seeking a Veteran Fee Waiver (for Initial Credential Fee only, see further information below)

Initial Credential Fee

$15.00 Application Fee

$25.00 Exam Fee

$40.00 Total Fee Attached

Reinstatement Fee (credential expired more than 4 years)

$15.00 Application Fee

$25.00 Exam Fee

$25.00 Late Renewal Fee

$65.00 Total Fee Attached

APPLICATION IS NOT COMPLETE UNTIL ALL OF THE

FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:

Fee and Application (including signature on Page 3)

Supporting Documentation (see Page i for instruction, i.e. college transcripts)

Is name on all credentials the same? If not, list former/maiden name(s):

ARE YOU A VETERAN? If yes, please view the Department website at http://dsps.wi.gov under “Licenses, Permits, and Registrations” and select

“Military Benefits Related to Licensure for Eligible Veterans Services Members and Spouses” for eligibility requirements.

If you qualify, are you requesting a waiver of your initial credentialing fee? Yes No

If Yes, provide a copy of your Department of Veterans Affairs voucher code and list your DVA Voucher Code Number:

You may contact the DVA at 1-800-WisVets or www.WISVET.com for assistance in obtaining your DVA Voucher Code and/or documents related to your training.

mailto:DSPSCredTrades@wi.gov http://dsps.wi.gov/ http://dva.state.wi.us/Pages/educationEmployment/Professional-Occupation-Licensure.aspx

Class Code 7642 Page 2 of 3 Committed to Equal Opportunity in Employment and Licensing

Wisconsin Department of Safety and Professional Services

EXPERIENCE TABLE:

Document at least 1,000 hours per year of experience for at least 4 years in the designing, installation, servicing or maintenance of HVAC systems or equipment. The witness must have observed or had knowledge of the number of work hours performed in supervising or performing the designing, installation, servicing or maintenance of HVAC systems or equipment. Copies of this page may be made to mail to witnesses to sign. (attach additional sheet(s) if necessary)

Month/Year Began Month/Year Ended Hours Signature of Witness Phone # of Witness

TO SCHEDULE AN UPCOMING EXAM:

Indicate a first date choice (1) and a second date choice (2) in the event one exam site is full.

Submit the fee and this application to the Department at least 30 days in advance of the exam date chosen.

Keep a copy of this application for your records. You may only schedule one future exam session at a time for each credential type.

You will receive a letter from DSPS confirming your upcoming exam, including the time, date and location of the exam.

If you need special accommodations, please contact us at DSPSCredTrades@wi.gov

Select One: A.M. (Starts at 8:00 a.m.) or P.M. (Starts at 1:00 p.m.)

Pewaukee – WCTC Education Center

800 Main St., Pewaukee, WI 53072

January 20, 2016 February 10, 2016 March 9, 2016 April 20, 2016

May 11, 2016 June 30, 2016 July 20, 2016 August 17, 2016

September 28, 2016 October 26, 2016 November 9, 2016 December 14, 2016

Eau Claire – The Plaza Hotel & Suites

1202 W Claremont Ave, Eau Claire, WI

54701

February 23, 2016 April 12, 2016 June 2, 2016 August 3, 2016

October 5, 2016 December 7, 2016

Appleton - Fox Valley Technical College

1825 North Bluemound Dr., Appleton

54914

January 6, 2016 March 22, 2016 May 24, 2016 July 14, 2016

September 7, 2016 November 22, 2016

RENEWAL REQUIREMENTS: Please view the Department website at http://dsps.wi.gov under “Licenses, Permits, and Registrations” and select

“Trades Professions.”

mailto:DSPSCredTrades@wi.gov

Class Code 7642 Page 3 of 3 Committed to Equal Opportunity in Employment and Licensing

Wisconsin Department of Safety and Professional Services

CERTIFICATION OF LEGAL STATUS:

I declare under penalty of law that I am (check one):

A citizen or national of the United States, or

A qualified alien or nonimmigrant lawfully present in the United States who is eligible to receive this professional license or credential as defined in the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, as codified in 8 U.S.C. §1601 et. Seq. (PRWORA).

For questions concerning PRWORA status, please contact the U.S. Citizenship and Immigration Services in the Department of Homeland

Security at 1-800-375-5283 or online at http://www.uscis.gov.

Should my legal status change during the application process or after a credential is granted, I understand that I must report this change to the

Wisconsin Department of Safety and Professional Services immediately.

CONTINUING DUTY OF DISCLOSURE

I understand that I have a continuing duty of disclosure during the application process. If information I have provided in this application becomes invalid, incorrect or outdated, I understand that I am obliged to provide any necessary information to ensure the information on my application remains current, valid, and truthful. I understand that Credentialing authorities may view acts of omission as dishonesty and that my duty of disclosure during the application process exists until licensure is granted or denied.

AFFIDAVIT OF APPLICANT

I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every respect. I understand that failure to provide requested information, making any materially false statement and/or giving any materially false information in connection with my application for a credential or for renewal or reinstatement of a credential may result in credential application processing delays; denial, revocation, suspension or limitation of my credential; or any combination thereof; or such other penalties as may be provided by law. I further understand that if I am issued a credential, or renewal, or reinstatement thereof, failure to comply with the statutes and/or administrative code provisions of the licensing authority will be cause of disciplinary action.

By signing below, I am signifying that I have read the above statements (Certification of Legal Status, Continuing Duty of Disclosure, and Affidavit of Applicant) and understand the obligation I have as an applicant or credential-holder should information I’ve provided to the Department of Safety and Professional Services change.

Signature: Date: / / http://www.uscis.gov/