Transcription of Renewal Application for Electrician Certification
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Renewal Application for Electrician Certification
(For Office Use) Tracking Nbr: Page 1 of 1 Form DLSE-ECF 6 (10/2015) State of California DIR Labor Standards and Enforcement Electrician Certification Program Phone (510) 286-3900 DL State _____ Driver s License # _____ Payment Amount $ _____ Date of Birth (MM/DD/YYYY) _____/_____/_____ Renewal Application for Electrician 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: _____ Type of Certification Examination Requested (check one): | | General Electrician | | Residential Electrician | | Fire/Life Safety Technician | | Voice Data Video Technician | | Nonresidential Lighting Technician GENERAL INSTRUCTIONS Please fill in the information above and complete a section below.
provider on our list relevant to e type of certification being renewed, a attach a copy of your completion hours. (If not, you do not qualify to RENEW timely and must retake the exam by marking box #4 and attach $200.00 fee) School Name(s):_____City: _____ School Name(s):
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