Electrical License Application Mail application with ...

1 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).

2 Failure to provide this information will be basis for Application refusal. Your SSN may be shared with other authorities only for tax-administration purposes and child-support enforcement (including identification). STEP 2 PREVIOUS LICENSES List all individual or contractor Electrical licenses you hold or have held in any state. Submit a copy of all out-of-state licenses with your Application . List License (s): STEP 3 License TYPE Please select a License type from the list below. Fees are nonrefundable. The Application instructions list the requirements and scope of each License . General supervising electrician (S) $ Limited maintenance electrician (LME) $ General journeyman (J) $ Limited residential electrician (LR) $ Limited supervising electrician (PS) $ Limited journeyman sign electrician (SIG) $ Limited journeyman manufacturing plant (PJ) $ Limited journeyman stage electrician (ST) $ Limited energy technician Class A (LEA) $ Limited building maintenance electrician (BME) $ Limited energy technician Class B (LEB) $ Limited renewable energy technician (LRT) $ Ltd.

3 Maintenance manufactured structures (LMM) $ STEP 4 TEST LOCATION Please refer to the enclosed list or our Web site to choose a test location. Reciprocal applicants do not test. Preferred testing location: Make check or money order payable to Department of Consumer & Business Services. If paying by credit card, applicant must sign credit card information box. Do not send cash. Secure fax for credit card payments: (503) 947-2333 Fee varies based on License type. Visa MasterCard Discover Phone: ( ) / Credit card number Expiration date Name of cardholder as shown on credit card $ Cardholder signature Amount DCBS Fiscal use only: 12104/0600 440-2570 (1/08/COM) Electrical License Application Page 2 STEP 5 EMPLOYMENT HISTORY List your experience in order, beginning with your present or most recent position.

4 If more space is needed, attach additional sheets. Please print Employer s name: Period of employment: Address: From: To: Hours worked per week: Phone: ( ) Position/title: Supervisor s name: Describe work performed: Employer s name: Period of employment: Address: From: To: Hours worked per week: Phone: ( ) Position/title: Supervisor s name: Describe work performed: Employer s name: Period of employment: Address: From: To: Hours worked per week.

5 Phone: ( ) Position/title: Supervisor s name: Describe work performed: Employer s name: Period of employment: Address: From: To: Hours worked per week: Phone: ( ) Position/title: Supervisor s name: Describe work performed: Applicant name: 440-2570 (1/08/COM) Electrical License Application Page 3 STEP 6 VERIFICATION OF WORK EXPERIENCE To provide proof of your work experience, submit an Electrical Experience Verification form (440-2570A) from each of your employers. OR Applicants relying on military experience must submit the following: Official documentation from supervising official showing the type and approximate hours of work experience Other reliable documentation verifying training and experience if supervisor not located STEP 7 PHOTOGRAPH OF APPLICANT Applicants must submit a 2 x 2 passport-style photo.

6 Write your name on the back of your photo and submit it with your Application . This photo will be printed on your License when it is issued. Please do not staple the photo. STEP 8 APPLICANT AFFIDAVIT 1. I hereby certify that, to the best of my knowledge, the information on this Application is complete and correct. 2. I understand that my License may be suspended, conditioned, or revoked if I have deliberately falsified my Application . ORS 3. I understand that, if I provide false information on this Application or cheat on a licensing examination, my Application will be denied and I may not apply for any License or be allowed to take any division-related examination for one year from the date of denial.

7 OAR 918-001-0040 4. I certify that I have read these statements and understand the terms of my License . Name (print): Applicant signature: Date: STEP 9 CHECKLIST FOR APPLICANTS 1. Application form completed (Form 440-2570) 2. Affidavit signed and dated (Step 8 on Application ) 3. Verification of work experience (Form 440-2570A) from each employer. 4. Additional documentation: Proof of completion of an Oregon-approved apprenticeship or training program Proof of completion of an out-of-state apprenticeship program recognized by the state of Oregon Official transcripts of classroom training 5. Proof of a high school diploma, GED, or equivalent.

8 A college degree will substitute. 6. Passport-style photo (2 x 2 ) with applicant s name on the back 7. Payment of fee DEPARTMENT USE ONLY Approved Signature: Date: Denied Signature: Date: Comments: Apprentice applicants must provide proof of completion of a recognized apprenticeship program. Applicant name: 440-2570A (7/06/COM/WEB) Page 1 Electrical Experience Verification Department of Consumer & Business Services Building Codes Division 1535 Edgewater St. NW, Salem, Oregon Phone: (503) 373-1268 Fax: (503) 378-2322 TTY: (503) 373-1358 Web: Mail verification to: Building Codes Division Box 14470 Salem, OR 97309-0404 Instructions: You must submit a separate experience verification form for each place of employment.

9 If you are submitting more than one form, do not overlap dates of employment. STEP 1 APPLICANT INFORMATION (please print) Name (applicant): Address: City: State: ZIP: Phone: ( ) Fax: ( ) E-mail: STEP 2 PERIOD OF EMPLOYMENT Employer s name: Period of employment: Address: From: To: Hours worked per week: Phone: ( ) Applicant s position/title: STEP 3 VERIFIER INFORMATION Applicants submitting verification of equivalent training and experience under OAR 918-030-0030(1)(c) must provide verification from the following persons: A current or previous employer actively involved with the applicant s work; The individual who supervised the work if the current or previous employer is no longer in business, is deceased, or otherwise cannot be located; or A co-worker who was directly involved in the work performed, only if both the employer and the supervisor cannot be located.

10 Co-worker verification must be accompanied by supporting documentation, such as employment records, showing that the verifier worked with the applicant and has knowledge of the work performed. Name of verifier: Address: Phone: ( ) City: State: ZIP: License number(s): Verifier s employment relationship to applicant: 440-2570A (7/06/COM/WEB) Electrical Experience Verification Page 2 Applicant (print name): STEP 4 VERIFIED EXPERIENCE 1. Enter the type of License you are applying for: 2. From License types on Page 3, choose the categories in which you have work experience and enter them under Category.