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Locksmith Application, Page 1

STATE OF TENNESSEE DEPARTMENT OF COMMERCE & INSURANCE DIVISION OF REGULATORY BOARDS LOCKSMITH LICENSING PROGRAM 500 JAMES ROBERTSON PARKWAY, 2ND FLOOR NASHVILLE, TENNESSEE 37243-0570 615.532.3369 FAX 615.532.2965 www.tn.gov/commerce/boards

FOR OFFICIAL USE ONLY File #

Xact #

LOCKSMITH LICENSE - APPLICATION

Instructions: Please read this entire application carefully. Complete all sections before returning with the required fees to the above address. Please note: application fees are not refundable. Submit additional information for any item on a separate sheet of paper.

CATEGORIES:

EDUCATION REQUIREMENTS:

; General Locksmith Automotive Safe & Vault

30 Hrs Basic Education Additional 8 Hrs Automotive Additional 8 Hrs S&V

EXPERIENCE REQUIREMENTS:

40 Hrs Experience Additional 10 Hrs Auto Experience Additional 10 Hrs S&V Experience

1.

PERSONAL DATA:

________-_____-________ Social Security Number

__________________________ Last Name

_____________________________ First Name

_____________________ Middle Name

Residence (Street) Address, Apt. No.

City

___________________________

___________________________ State

______________________ Zip Code

() (Area Code) Home Phone Number

_________________________________________________________ E-mail address (If available)

_____/_____/_________ Date of Birth (M/D/Y)

______________________ Place (City,State) of Birth

a.

Are you a United States Citizen?

_______

_____

______

Sex(M/F)

Race

Height

_____

_____

Hair

Eyes

______ Weight

Yes No

b.

Have you ever used a name other than the one by which you are applying?

Yes No

If yes, give the name(s):

Explain why the name(s) was used:

Locksmith Company you will be employed by: (Locksmith Company Registration Required)

Company Name

Registration Number

___________________________________________________ Business Address

_______________________________________________

City

State

______________ Zip Code

(_________)_____________________ (Area Code) Telephone Number

IN-1654 Rev 03/08

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