APPLICATION FOR ELECTRICIAN EXAMINATION AND CERTIFICATION MAX 300 Electrical Form

User Manual: MAX-300

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(For Office Use) Tracking Nbr: Page 1 of 2 Form DLSE-ECF1 (3/2015)
State of California
D
IR – Labor Standards and Enforcement
www.dir.ca.gov/dlse/ecu/ElectricalTrade.html
Electrician Certification Program
Phone (510) 286
-3900
DL State ____ Driver’s License # ________________
Payment Amount $ ______
Date of Birth (MM/DD/YYYY) ______/______/______
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: Zip: ____________-__________________________
Day Phone: (____)_____-_______ 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 Fire/Life Voice Data
Nonresidential
For
USE ONLY YOUR EXAM COLUMNS
Electrician Electrician
Safety
Tech
Video
Tech Lighting Tech
Office
Minimum Credit Hours Required =>
8,000 4,800 4,000 4,000 2,000
Use
Stock Room and Material Handling
Residential Wiring
-- n/a -- -- n/a -- -- n/a --
Commercial Wiring
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Industrial Wiring
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Voice Data and Video Installation
-- n/a -- -- n/a -- -- n/a --
Underground Conduit Installation
-- n/a -- -- n/a -- -- n/a --
Troubleshooting and Maintenance
-- n/a --
Finish Work and Fixtures
-- n/a -- -- n/a -- -- n/a --
Fire/Life Safety, Nurse Call
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Fire/Life Safety
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Nurse Call Systems
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Installations, including wire pulling,
terminations, control panels devices
and finish work
-- n/a -- -- n/a -- -- n/a --
Proprietary systems training related to
Fire/Life Safety
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Trade specific training related to Voice,
Data, Video
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Maintenance of Lighting Fixtures
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Installation of Retrofit Fixtures
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Troubleshooting and Repairing
-- n/a -- -- n/a -- -- n/a -- -- n/a --
Your TOTAL Credit Hours =>
Max 300
Max 3,000
Max 6,000
Max 6,000
Max 1,500
Max 1,500
Max 1,500
Max 750
Max 750 Max 750
Max 300
Max 300
Max 300
Max 300
Max 300
Max 300
Max 300
Max 300
Max 4,800
Max 150
Max 150
Max 600
Max 600
Max 4,000 Max 4,000
Max 1,750
Max 500
Max 600
Max 600
Clear
0
0
0
0
0
75.00
0.00
0.00
0.00
0.00
0.00
75.00
(For Office Use) Tracking Nbr: Page 2 of 2 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 | | Fire/Life Safety Technician
| | Voice Data Video Technician | | Nonresidential Lighting Technician
Exam Language Selection (check one): | | English | | 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

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