Scribd Logo
Upload

Welcome to Scribd!

  • 73 views

    Application For: Electrician Examination and Certification

    Uploaded by

    José Juan Campuzano Gonzalez
    This document is an application for electrician examination and certification from the State of California. It requests information such as name, address, experience details, and payment. Applicants must provide proof of experience, such as an apprenticeship certificate or hours worked, and pay a $75 application fee plus $100 for each exam requested. The application certifies that all information provided is true and should be mailed to the DIR-Division of Labor Standards Enforcement Electrician Certification Unit.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application For: Electrician Examination and Certification

    Uploaded by

    José Juan Campuzano Gonzalez
    73 views2 pages
    This document is an application for electrician examination and certification from the State of California. It requests information such as name, address, experience details, and payment. Applicants must provide proof of experience, such as an apprenticeship certificate or hours worked, and pay a $75 application fee plus $100 for each exam requested. The application certifies that all information provided is true and should be mailed to the DIR-Division of Labor Standards Enforcement Electrician Certification Unit.

    Original Title

    Untitled

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is an application for electrician examination and certification from the State of California. It requests information such as name, address, experience details, and payment. Applicants must provide proof of experience, such as an apprenticeship certificate or hours worked, and pay a $75 application fee plus $100 for each exam requested. The application certifies that all information provided is true and should be mailed to the DIR-Division of Labor Standards Enforcement Electrician Certification Unit.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    73 views2 pages

    Application For: Electrician Examination and Certification

    Uploaded by

    José Juan Campuzano Gonzalez
    This document is an application for electrician examination and certification from the State of California. It requests information such as name, address, experience details, and payment. Applicants must provide proof of experience, such as an apprenticeship certificate or hours worked, and pay a $75 application fee plus $100 for each exam requested. The application certifies that all information provided is true and should be mailed to the DIR-Division of Labor Standards Enforcement Electrician Certification Unit.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    Clear Print

    State of California DL State ____ Driver’s License # ________________


    DIR – Labor Standards and Enforcement
    www.dir.ca.gov/dlse/ecu/ElectricalTrade.html
    Payment Amount $ ______
    Electrician Certification Program Date of Birth (MM/DD/YYYY) ______/______/______
    Phone (510) 286-3900

    Application for Electrician Examination and Certification


    Please PRINT or TYPE all information in INK
    Last Name: First Name: MI:
    Name must match U. S. Drivers License or State ID:

    Mailing Address:
    City: ____________________________State: Zip: ____________-__________________________
    Day Phone: (____)_____-_______ Email: ___________________________________________________

    Note - You also need to attach the following to this application:


    (a) Proof of experience as required under CCR 8, Ch. 2, Part IV, Section 291 of the regulations ‘check only one’ and
    attach the Social Security Administration Employment History Report (SSN# redacted)[AB 1346] or if coming from
    another country submit verification letter(s) from employer(s):

    (1) Apprenticeship Certificate (attach copy of Certificate & SSA Report (United States only). Read section (a) for
    other required proof. [Regulations 291.1(a)(1) & AB 1346]
    (2) On-the-job experience (enter your hours below & SSA Report) and/or Other experience, including military
    (attach proof & SSA Report). Read section (a) for other required proof [Regulations 291.1(a)(2) & (c) & AB 1346]
    (3) Other state license (attach copy of License & SSA Report). Read section (a) for other required proof.
    [Regulations 291.1(b) & AB 1346]
    (4) * Apprentice in last year of training (attach copy of DAS1 form) [Regulations 291.2(f)] *Note: No certification card
    will be issued until completion of the term of apprenticeship.
    (5) * Electrician Trainee has completed Approved Curriculum (attach copy of Certificate) *Note: No certification card
    will be issued until the required on-the-job experience is acquired. The SSA report needs to be submitted
    once you complete your experience. Read section (a) for other required proof. [Regulations 291.2(g) & AB 1346]
    (6) NICET Certification in Fire Alarm Systems at Level II or above (for Fire/Life Safety Exam Only)
    (attach copy of Certificate & SSA Report). Read section (a) for other required proof. [Regulations 291.1(a)(2) & AB 1346]

    (a) (2) ENTER YOUR ACTUAL HOURS OF WORK HERE But NOT more than the maximum hours for your categories listed.

    Category General Residential Fire/Life Voice Data Nonresidential For


    Safety Video
    USE ONLY YOUR EXAM COLUMNS Electrician Electrician Tech Tech Lighting Tech Office
    Minimum Credit Hours Required => 8,000 4,800 4,000 4,000 2,000 Use
    Stock Room and Material Handling Max 300 Max 300 Max 300 Max 300 Max 150
    Residential Wiring Max 3,000 Max 4,800 -- n/a -- -- n/a -- -- n/a --
    Commercial Wiring Max 6,000 -- n/a -- -- n/a -- -- n/a -- -- n/a --
    Industrial Wiring Max 6,000 -- n/a -- -- n/a -- -- n/a -- -- n/a --
    Voice Data and Video Installation Max 1,500 Max 150 -- n/a -- -- n/a -- -- n/a --
    Underground Conduit Installation Max 750 Max 300 -- n/a -- -- n/a -- -- n/a --
    Troubleshooting and Maintenance Max 1,500 Max 600 Max 750 Max 750 -- n/a --
    Finish Work and Fixtures Max 600 Max 600 -- n/a -- -- n/a -- -- n/a --
    Fire/Life Safety, Nurse Call Max 600 -- n/a -- -- n/a -- -- n/a -- -- n/a --
    Fire/Life Safety -- n/a -- Max 300 -- n/a -- -- n/a -- -- n/a --
    Nurse Call Systems -- n/a -- -- n/a -- Max 300 -- n/a -- -- n/a --
    Installations, including wire pulling,
    terminations, control panels devices Max 4,000 Max 4,000
    and finish work -- n/a -- -- n/a -- -- n/a --
    Proprietary systems training related to
    Fire/Life Safety -- n/a -- -- n/a -- Max 300 -- n/a -- -- n/a --
    Trade specific training related to Voice,
    Data, Video -- n/a -- -- n/a -- -- n/a -- Max 300 -- n/a --
    Maintenance of Lighting Fixtures -- n/a -- -- n/a -- -- n/a -- -- n/a -- Max 1,750
    Installation of Retrofit Fixtures -- n/a -- -- n/a -- -- n/a -- -- n/a -- Max 1,500
    Troubleshooting and Repairing -- n/a -- -- n/a -- -- n/a -- -- n/a -- Max 500
    Your TOTAL Credit Hours => 0 0 0 0 0
    75.00 0.00 0.00 0.00 0.00 0.00 75.00
    (For Office Use) Tracking Nbr: Page 1 of 2 Form DLSE-ECF1 (09/2021)
    State of California
    Department of Industrial Relations
    Division of Labor Standards Enforcement
    www.dir.ca.gov/dlse/ecu/ElectricalTrade.html
    Electrician Certification Program

    Type of Certification Examination Requested (check one or more):


    | | General Electrician | | Residential Electrician | | Fire/Life Safety Technician
    | | Voice Data Video Technician | | Nonresidential Lighting Technician
    Exam Language Selection (check one): | | English | | Spanish

    (b) A fee of $75 for this application (non-refundable), plus $100 for EACH examination checked above.
    Exact payment by check or money order must be payable to ‘DIR – Electrician Certification Fund’.

    Any exam must be taken within 1 year from the date of notification of eligibility to take the original examination.
    I certify under penalty of perjury that all statements and attachments are true and correct.

    Signature: Date:
    Submit form with original signature and keep a copy for your records.
    Incomplete or inaccurately paid applications will NOT be approved.
    Mail this completed form with all required attachments to:
    State of California
    DIR-Division of Labor Standards Enforcement Attn: Electrician Certification Unit
    PO Box 511286 Los Angeles, CA 90051-7841

    (For Office Use) Tracking Nbr: Page 2 of 2 Form DLSE-ECF1 (10/2021)

    You might also like