Transcription of Electrical License Application Mail application with ...
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Electrical License Application Mail application with ...
Page 1 440-2570 (1/08/COM) Electrical License Application Department of Consumer & Business Services Building Codes Division 1535 Edgewater St. NW, Salem, Oregon Phone: (503) 373-1268 Fax: (503) 378-2322 Web: Mail Application with payment to: DCBS Fiscal Services Box 14610 Salem, OR 97309-0445 Important: Read the Application instructions before completing this form. Please complete all steps before submitting your Application and refer to the checklist at the end of this form. STEP 1 APPLICANT INFORMATION (please print) Last First Middle initial Name: Address (street or Box): City: State: ZIP: Phone: ( ) Fax: ( ) E-mail: Social Security number (Required, ORS ): Your Social Security number is required for BCD licenses, certifications, and registrations according to ORS , ORS , 42 USC 405 (c)(2)(C)(i), and 42 USC 666(a)(13). Failure to provide this information will be basis for Application refusal.
440-2570 (1/08/COM) Page 2 Electrical License Application STEP 5 EMPLOYMENT HISTORY List your experience in order, beginning …
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