Personal Male Female

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Personal Male Female
Name	Social Security Number
Aliases	Date of Birth
Phone Number	E-mail Address
Permanent Mailing Address	City

State	Zip Code


Business
Business Name M	Phone Number
Physical Address	City
State	Zip Code
Additional Contact Information
Fax Number	Mobile Pager


Indicate which Classes of License(s) for which you are Applying (You Must Select at Least One)
Electrical Contractor* Electrical Sign Contractor Master Electrician Master Sign Electrician Journeyman Electrician Journeyman Sign Electrician Residential Wireman no exam required Maintenance Electrician Electrical Apprentice
Have you ever held an Electrical License? Yes No If Yes, What Class(es)?
Class	Original Date of Issue

Expiration Date	City

State of Issue	Exam Passed

Class	Original Date of Issue

Expiration Date	City

State of Issue	Exam Passed



Have you ever been convicted of or pleaded guilty or no contest (nolo contendere) to any misdemeanor or felony, other than a minor traffic violation. oris there any such charge now pending? Yes No If you answered yes, please explain.
Employment History DESCRIBE THE LAST SIX YEARS OF YOUR EMPLOYMENT HISTORY. LIST IN DETAIL YOUR JOB DUTIES PERTAINING TO ELECTRICAL EXPEREINCE AND WORK. BE AS THOROUGH AS POSSIBLE. NOTE: TO AVOID DELAY IN SUBMITTING YOUR APPLICATION, THE FOLLOWING SECTIONS MUST BE COMPLETED. EMPLOYER 1
Employer	Employer's Telephone Number
Mailing Address	City
State Master's Name	Zip Master's License Number
Hours of Years of Experience	Hours / Years
Describe Job Duties in Detail

EMPLOYER 2
Employer	Employer's Telephone Number
Mailing Address	City
State Master's Name	Zip Master's License Number
Hours of Years of Experience	Hours / Years
Describe Job Duties in Detail EMPLOYER 3

Employer	Employer's Telephone Number
Mailing Address	City
State Master's Name	Zip Master's License Number
Hours of Years of Experience	Hours / Years
Describe Job Duties in Detail