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. If more space is needed, attach additional sheets.

4 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: 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.

5 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. 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.

6 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. 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.

7 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. 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.

8 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. 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.

9 (See example, below.) 3. Under Total hours, enter the hours of work experience in each category. The division will consider no more than 2,000 hours of experience per year. OAR 918-282-0030(4). 4. Enter your specific work duty experience under Description of duties. If you need more information, see , Statutes and Rules, Oregon Administrative Rules, click on 918-282, then scroll down to the desired License type. 5. Make copies of this page, if needed. Category Total hours Description of duties (example) Residential wiring 2000 Installations, wire pulling, service and panel, conduit, flex, metal romex boxes, Electrical heating systems STEP 5 VERIFIER CONFIRMATION As the verifier of the preceding information, I confirm that it is true and correct to the best of my knowledge.

10 Verifier name (please print): Verifier signature: Date: 440-2570A (7/06/COM/WEB) Electrical Experience Verification Page 3 Electrical WORK EXPERIENCE CATEGORIES General journeyman (J) Limited energy, Class A (LEA) General supervisor (S) Limited energy, Class B (LEB) Limited residential (LR) Stockroom, materials handling Residential wiring Protective signaling (fire alarm, nurse call, burglar alarm, security and voice evacuation systems that are part of a fire or life safety system) (LEA only) Commercial installations HVAC Industrial installations Medical Troubleshooting and maintenance Boiler controls Finishing and fixture hanging Intercom, paging, sound, CCTV Signal and control systems Clock systems Remodeling Data telecommunications Underground construction Instrumentation Security Limited supervisor (PS) Stockroom, materials handling, shop and service Limited plant journeyman (PJ) Limited maintenance electrician (LME) Electrical circuits Limited energy wiring.