Transcription of Affidavit of Experience for Washington Electrical Trainees ...
1 F500-149-000 Affidavit of Experience for Washington Electrical Trainees 11-2021 GL 1355 Index: AFFT Affidavit of Experience for Washington Electrical Trainees Mail your Affidavit and update fee* to: trainee Responsibilities: Mail your original Affidavit to the address on this form: No copies of copies. No email. No faxes. Affidavit deadlines: From the expiration date on your training certificate , you have 180 days to turn in your affidavits for the previous 2 years. Affidavits received by L&I after the deadline are not approvable. For receipt of delivery, use certified mail. Affidavits are date stamped upon receipt at L&I. Exceptions: No deadline for affidavits of hours worked while registered in approved Apprenticeship programs. Affidavit must be signed program by Training Director.
2 L&I Electrical Program PO Box 44460 Olympia WA 98504-4460 *Update Fee of $ is required for each affidavitwhen received more than 30 days after your trainingcertificate expiration date. No online payment options. No fee required to submit earlier. No fee required for affidavits for hours worked whileregistered in an approved Apprenticeship program. Questions? Call 360-902-5269 Affidavit : Please print clearly in ink. Make no omissions, errors, or alterations. trainee must submit the original copy to L&I. I, Name of Electrical Administrator/Master Electrician or Employer s Authorized Signer or Apprenticeship Training Director of , attest and Name of Employer or Apprenticeship Electrical Contractor License # or UBI # or WSATC Apprenticeship ID # certify that , was Name of Washington L&I Electrical trainee trainee s L&I Training certificate # supervised in accordance with RCW and WAC 296-46B from to (Claim no more than MM/DD/YYYY MM/DD/YYYY 24 months per Affidavit ) while engaged in the Electrical construction trade for the number hours in WAC 296-46B-920 categories below.
3 Hours Category (75% supervision required) Hours Category (100% supervision required) (01)Commercial or Industrial(03A) Domestic Well (02)Residential(06B) HVAC/Refrigeration Restricted (03)Pump and Irrigation(07A) Non-Residential Lighting Maintenance (04)Signs(07B) Residential Maintenance (06)Limited Energy System(07C) Restricted Non-Residential Maintenance (06A) HVAC/Refrigeration(07D) Appliance Repair (07)Non-Residential Maintenance(07E) Equipment Repair Signature Sign below in the presence of a Notary Public (10)Door, Gate, and Similar SystemsI hereby certify that the information on this Affidavit is true and accurate. I acknowledge that the department may issue citations for false statements or material misrepresentation or other violations per RCW and WAC 296-46B. X Signature of person named above Electrical Administrator/Master Electrician or Employer s Authorized Signer or Apprenticeship Training Director Signed before me on For L&I Use Transaction ID and Date Stamp Field MM/DD/YYYY X Signature of Notary Public Residing in Notary Stamp or Seal below must be affixed in ink and be capable of being photocopied.
4 Electronic notarization accepted.
