ARKANSAS BOARD OF ELECTRICAL EXAMINERS
ARKANSAS DEPARTMENT OF LABOR
10421 West Markham, Little Rock, AR |
72205-2190 |
Phone: 501-682-4549 Fax: 501-682-1765 |
TRS: 800-285-1131 |
http://www.arkansas.gov/labor/divisions
THIS APPLICATION MUST BE FILLED OUT COMPLETELY
CHECK APPROPRIATE BOXES: (1) ❑ Master |
(2) |
❑ Examination |
❑ Residential Master |
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❑ Reciprocal |
❑ Journeyman |
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❑ Temporary |
❑Residential Journeyman
❑Industrial Maintenance
❑Air Conditioning Electrician
❑Specialist Sign Electrician
Date _______________________
Name ______________________________________________ Age _____ Date of Birth ___________
LastFirstMiddle
Residence Address ___________________________________________________________________
StreetCityStateZip Code
Mailing Address ______________________________________________________________________
Street |
City |
State |
Zip Code |
Social Security # _________________________________ |
County ___________________________ |
Home Phone # (________)___________________ Other Phone # (________)___________________
Arkansas Code Annotated §17-1-104 (Repl. 2001) requires the Electrical Division to transfer name, address, and social security number information on applicants to the Office of Child Support Enforcement. Social security numbers shall otherwise be maintained in a confidential manner as required by this statute.
Have you previously made application for examination with this Board? ❑ No ❑ Yes, Date: __________
Have you ever held an electrician's license? ❑ No ❑Yes, If so, where _______ License # ___________
(submit photocopy)
License type and level ___________________ Original issue date ___________ Valid until _________
Was the license issued by examination? ❑ No ❑ Yes Exam Date_________________
What testing firm administered the examination: __________________________ Exam Score _______
Have you ever had an electrician's license revoked? ❑ No ❑ Yes
If Yes, by whom and for what reason? ___________________________________________________
Have you attended an apprenticeship school? ❑ No ❑ Yes If Yes, number of semesters _______
If Yes, where? ______________________________________________________________________
Apprenticeship Registration/License Number ______________________________________________
AR Electrician Application Form.doc Rev. 07/2009 |
Page 1 of 5 |
INSTRUCTIONS FOR LISTING WORK EXPERIENCE AND TRADE-RELATED EDUCATION
PLEASE READ CAREFULLY
Please complete PART I and PART II in detail.
PART I - WORK EXPERIENCE (See Page 3)
The Arkansas Board of Electrical Examiners may contact your present or previous employers to verify your work experience as stated herein.
•Verification of employment must be provided by NOTARIZED original letters (not photocopies) or by Affidavit of Employment Experience (see Page 5) from previous or current employers. The verification must include exact employment dates and the exact type of electrical work performed.
•Your qualifications will be determined on the basis of information provided by you on this application. It must be factual, clear and complete. Use additional sheets if necessary.
•Provide photocopies of any electrical licenses you presently hold or have previously held.
•If you have Supervision experience and/or were the Owner of an electrical contracting company, you may attach additional information to your application. You should submit a NOTARIZED letter describing your work experience along with a copy of your advertisement in the telephone directory, a copy of your business stationary, a list of jobs contracted by your company, a photocopy of any state or city business license(s), and any other documents supporting the length of time you have been in business.
PART II - TRADE RELATED EDUCATION AND FORMAL INSTRUCTION (See Page 4)
Read carefully the descriptions of the three classifications of education or instruction listed below. Then turn to Page 4 and, in the space provided, give the information requested. Make your answers as complete and clear as possible. A transcript of credits must be submitted to receive credit for school time.
1.Formal Apprentice Training: If you have been employed by an employer with an approved electrical apprentice training program, list the program and the dates that you were enrolled. If completed, attach a copy of the completion certificate. Requests for acceptance of apprenticeship training must be accompanied by a “Release for Test” form signed by the apprenticeship program and the Arkansas Department of Career Education.
2.Electrical Engineer: A degree in electrical engineering plus two (2) years experience will be accepted for application for a master examination.
3.Military Training in Electrical Wiring. Show in detail exactly what kind of training, schooling, or work experience you received directly related to wiring for installing and repairing electrical apparatus and equipment for light, heat and power. Include the length of time spent and any other information that will assist in evaluating the degree of electrical experience that you have had in construction in this classification.
Submit the application and all supporting documentation to:
ARKANSAS BOARD OF ELECTRICAL EXAMINERS ARKANSAS DEPARTMENT OF LABOR
10421 WEST MARKHAM LITTLE ROCK, AR 72205-2190
AR Electrician Application Form.doc Rev. 07/2009 |
Page 2 of 5 |
PART I – WORK EXPERIENCE
LIST PRESENT AND PREVIOUS EMPLOYERS.
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EMPLOYER INFORMATION |
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AR Electrician Application Form.doc Rev. 07/2009 |
Page 3 of 5 |
PART II – TRADE RELATED EDUCATION AND FORMAL INSTRUCTION:
1. FORMAL APPRENTICE TRAINING PROGRAM:
NAME OF PROGRAM /SCHOOL AND COURSE:
DATES: Started / |
CREDIT |
Completed |
HOURS |
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2.EDUCATION - VOCATIONAL OR TRADE, CORRESPONDENCE, COLLEGE:
A transcript must be included with the application.
NAME OF SCHOOL AND COURSE:
DATES: Started / |
CREDIT |
Completed |
HOURS |
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3.MILITARY TRAINING (Submit photocopy of your DD-214 form)
Military training or experience in electrical work must be detailed and submitted for evaluation with the application.
NAME OF SCHOOL AND COURSE:
DATES: Started / |
CREDIT |
Completed |
HOURS |
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I HEREBY STATE THAT THE INFORMATION CONTAINED IN THIS APPLICATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. I AGREE TO ABIDE BY ALL RULES AND REGULATIONS OF THE ARKANSAS BOARD OF ELECTRICAL EXAMINERS.
(PLEASE NOTE: FAXED COPIES ARE NOT ACCEPTED)
__________________________________ |
_____________________________________________ |
Date |
Signature of Applicant |
AR Electrician Application Form.doc Rev. 07/2009 |
Page 4 of 5 |
STATE OF ARKANSAS
ARKANSAS DEPARTMENT OF LABOR
ARKANSAS BOARD OF ELECTRICAL EXAMINERS
10421 WEST MARKHAM • LITTLE ROCK, AR 72205-2190
Phone: 501-682-4549 |
Fax: 501-682-1765 |
TRS: 800-285-1131 |
AFFIDAVIT OF EMPLOYMENT EXPERIENCE
TO: Arkansas Board of Electrical Examiners
Applicant Name:
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Dates of verification (mm/dd/yyyy) : |
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Amount of hours in each type of work: |
Residential: |
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Hours |
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Commercial: |
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Hours |
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Industrial Construction: |
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Hours |
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Industrial Maintenance: |
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Hours |
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Sign Specialist: |
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Hours |
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TOTAL HOURS: |
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Work listed above was performed under the supervision of:
Master Electrician: |
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License Number: |
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Company Name: |
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Description of Applicant’s job duties: |
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I state under oath the above and foregoing employment history is true and correct to the best of my knowledge and belief.
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Employer's Signature
Subscribed and sworn to before me this
______ day of ______________, 20_______.
_______________________________
Notary Public
Employer's Name ( please print or type)
Company
License Number or Title
A separate affidavit must be furnished for each employer listed on the license application.
(Photocopy this form as needed.)
AR Electrician Application Form.doc Rev. 07/2009 |
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