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Application For: Electrician Examination and Certification

This document is an application for electrician examination and certification from the State of California. It requests information such as name, address, experience details, and payment. Applicants must provide proof of experience, such as an apprenticeship certificate or hours worked, and pay a $75 application fee plus $100 for each exam requested. The application certifies that all information provided is true and should be mailed to the DIR-Division of Labor Standards Enforcement Electrician Certification Unit.

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José Juan Campuzano Gonzalez
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97 views

Application For: Electrician Examination and Certification

This document is an application for electrician examination and certification from the State of California. It requests information such as name, address, experience details, and payment. Applicants must provide proof of experience, such as an apprenticeship certificate or hours worked, and pay a $75 application fee plus $100 for each exam requested. The application certifies that all information provided is true and should be mailed to the DIR-Division of Labor Standards Enforcement Electrician Certification Unit.

Uploaded by

José Juan Campuzano Gonzalez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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State of California DL State ____ Driver’s License # ________________


DIR – Labor Standards and Enforcement
www.dir.ca.gov/dlse/ecu/ElectricalTrade.html
Payment Amount $ ______
Electrician Certification Program Date of Birth (MM/DD/YYYY) ______/______/______
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: 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


Safety Video
USE ONLY YOUR EXAM COLUMNS Electrician Electrician Tech Tech Lighting Tech Office
Minimum Credit Hours Required => 8,000 4,800 4,000 4,000 2,000 Use
Stock Room and Material Handling Max 300 Max 300 Max 300 Max 300 Max 150
Residential Wiring Max 3,000 Max 4,800 -- n/a -- -- n/a -- -- n/a --
Commercial Wiring Max 6,000 -- n/a -- -- n/a -- -- n/a -- -- n/a --
Industrial Wiring Max 6,000 -- n/a -- -- n/a -- -- n/a -- -- n/a --
Voice Data and Video Installation Max 1,500 Max 150 -- n/a -- -- n/a -- -- n/a --
Underground Conduit Installation Max 750 Max 300 -- n/a -- -- n/a -- -- n/a --
Troubleshooting and Maintenance Max 1,500 Max 600 Max 750 Max 750 -- n/a --
Finish Work and Fixtures Max 600 Max 600 -- n/a -- -- n/a -- -- n/a --
Fire/Life Safety, Nurse Call Max 600 -- n/a -- -- n/a -- -- n/a -- -- n/a --
Fire/Life Safety -- n/a -- Max 300 -- n/a -- -- n/a -- -- n/a --
Nurse Call Systems -- n/a -- -- n/a -- Max 300 -- n/a -- -- n/a --
Installations, including wire pulling,
terminations, control panels devices Max 4,000 Max 4,000
and finish work -- n/a -- -- n/a -- -- n/a --
Proprietary systems training related to
Fire/Life Safety -- n/a -- -- n/a -- Max 300 -- n/a -- -- n/a --
Trade specific training related to Voice,
Data, Video -- n/a -- -- n/a -- -- n/a -- Max 300 -- n/a --
Maintenance of Lighting Fixtures -- n/a -- -- n/a -- -- n/a -- -- n/a -- Max 1,750
Installation of Retrofit Fixtures -- n/a -- -- n/a -- -- n/a -- -- n/a -- Max 1,500
Troubleshooting and Repairing -- n/a -- -- n/a -- -- n/a -- -- n/a -- Max 500
Your TOTAL Credit Hours => 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 1 of 2 Form DLSE-ECF1 (09/2021)
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

(For Office Use) Tracking Nbr: Page 2 of 2 Form DLSE-ECF1 (10/2021)

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