APPLICATION FOR ELECTRICIAN EXAMINATION AND CERTIFICATION MAX 300 Electrical Form

User Manual: MAX-300

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State of California

DL State ____ Driver’s License # ________________
Payment Amount $ ______
Date of Birth (MM/DD/YYYY) ______/______/______

DIR – Labor Standards and Enforcement
www.dir.ca.gov/dlse/ecu/ElectricalTrade.html

Electrician Certification Program
Phone (510) 286-3900

Application for Electrician Examination and 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:

Day Phone: (____)_____-_______

Zip: ____________-__________________________

Email: ___________________________________________________

Note - You also need to attach the following to this application:
(a) Proof of experience as required under CCR 8, Ch. 2, Part IV, Section 291 of the regulations ‘check only one’ and
attach the Social Security Administration Employment History Report (SSN# redacted)[AB 1346] or if coming from
another country submit verification letter(s) from employer(s):
(1) Apprenticeship Certificate (attach copy of Certificate & SSA Report (United States only). Read section (a) for
other required proof. [Regulations 291.1(a)(1) & AB 1346]
(2) On-the-job experience (enter your hours below & SSA Report) and/or Other experience, including military
(attach proof & SSA Report). Read section (a) for other required proof [Regulations 291.1(a)(2) & (c) & AB 1346]
(3) Other state license (attach copy of License & SSA Report). Read section (a) for other required proof.
[Regulations 291.1(b) & AB 1346]
(4) * Apprentice in last year of training (attach copy of DAS1 form) [Regulations 291.2(f)] *Note: No certification card
will be issued until completion of the term of apprenticeship.
(5) * Electrician Trainee has completed Approved Curriculum (attach copy of Certificate) *Note: No certification card
will be issued until the required on-the-job experience is acquired. The SSA report needs to be submitted
once you complete your experience. Read section (a) for other required proof. [Regulations 291.2(g) & AB 1346]
(6) NICET Certification in Fire Alarm Systems at Level II or above (for Fire/Life Safety Exam Only)
(attach copy of Certificate & SSA Report). Read section (a) for other required proof. [Regulations 291.1(a)(2) & AB 1346]
(a) (2) ENTER YOUR ACTUAL HOURS OF WORK HERE But NOT more than the maximum hours for your categories listed.
Category

General

Residential

USE ONLY YOUR EXAM COLUMNS
Minimum Credit Hours Required =>

Electrician

Electrician

Stock Room and Material Handling
Residential Wiring
Commercial Wiring
Industrial Wiring
Voice Data and Video Installation
Underground Conduit Installation
Troubleshooting and Maintenance
Finish Work and Fixtures
Fire/Life Safety, Nurse Call
Fire/Life Safety
Nurse Call Systems
Installations, including wire pulling,
terminations, control panels devices
and finish work
Proprietary systems training related to
Fire/Life Safety
Trade specific training related to Voice,
Data, Video
Maintenance of Lighting Fixtures
Installation of Retrofit Fixtures
Troubleshooting and Repairing

Max 300
Max 3,000
Max 6,000
Max 6,000
Max 1,500
Max 750
Max 1,500
Max 600
Max 600

Max 300
Max 4,800
-- n/a --- n/a -Max 150
Max 300

Your TOTAL Credit Hours =>

75.00
(For Office Use) Tracking Nbr:

8,000

4,800

Voice Data
Video
Tech

Max 300
-- n/a --- n/a --- n/a --- n/a --- n/a -Max 750

Max 300

-- n/a --- n/a --- n/a -Max 300

-- n/a --- n/a --- n/a --- n/a --

4,000

Max 600
Max 600
-- n/a -Max 300

-- n/a --- n/a --

Fire/Life
Safety
Tech

-- n/a --

4,000

For

Lighting Tech

Office
Use

2,000

Max 150
-- n/a --- n/a --- n/a --- n/a --- n/a --- n/a --- n/a --- n/a --- n/a --- n/a --

-- n/a --- n/a --- n/a --- n/a --- n/a -Max 750

Max 4,000

Nonresidential

Max 4,000

-- n/a --

-- n/a --

-- n/a --

-- n/a --

Max 300

-- n/a --

-- n/a --

-- n/a --- n/a --- n/a --- n/a --

-- n/a --- n/a --- n/a --- n/a --

-- n/a --- n/a --- n/a --- n/a --

Max 300
-- n/a --- n/a --- n/a --

-- n/a -Max 1,750
Max 1,500
Max 500

0

0.00

0

-- n/a --

0

0.00

0

0.00
Page 1 of 2

0

0.00

0.00

75.00

Form DLSE-ECF1 (3/2015)

State of California
Department of Industrial Relations
Division of Labor Standards Enforcement
www.dir.ca.gov/dlse/ecu/ElectricalTrade.html

Electrician Certification Program

Type of Certification Examination Requested (check one or more):
|

| General Electrician |
|

| Residential Electrician

| Voice Data Video Technician |

Exam Language Selection (check one):

|

| English

|

| Fire/Life Safety Technician

| Nonresidential Lighting Technician
|

| Spanish

(b) A fee of $75 for this application (non-refundable), plus $100 for EACH examination checked above.
Exact payment by check or money order must be payable to ‘DIR – Electrician Certification Fund’.

Any exam must be taken within 1 year from the date of notification of eligibility to take the original examination.

I certify under penalty of perjury that all statements and attachments are true and correct.
Signature:

Date:
Submit form with original signature and keep a copy for your records.
Incomplete or inaccurately paid applications will NOT be approved.
Mail this completed form with all required attachments to:
State of California
DIR-Division of Labor Standards Enforcement Attn: Electrician Certification Unit
PO Box 511286
Los Angeles, CA 90051-7841

(For Office Use) Tracking Nbr:

Page 2 of 2

Form DLSE-ECF1 (3/2015)
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