Oregon Form 440 2570 – Fill Out and Use This PDF

		DCBS Fiscal Services
	Department of Consumer & Business Services
		P.O. Box 14610
	Building Codes Division • 1535 Edgewater St. NW, Salem, Oregon
		Salem, OR 97309-0445
	Phone: (503) 373-1268 • Fax: (503) 378-2322
	Web: bcd.oregon.gov

Important: Read the application instructions before completing this form. Please complete all steps before submitting your application and refer to the checklist at the end of this form.

STEP 1			APPLICANT INFORMATION (please print)
Last					First		Middle initial
Name:
Address (street or P.O. Box):
City:					State:		ZIP:
Phone: (	)		Fax: (	)		E-mail:
Social Security number (Required, ORS 25.785):					–	–

Your Social Security number is required for BCD licenses, certifications, and registrations according to ORS 25.785, ORS 305.385, 42 USC § 405 (c)(2)(C)(i), and 42 USC § 666(a)(13). Failure to provide this information will be basis for application refusal. Your SSN may be shared with other authorities only for tax-administration purposes and child-support enforcement (including identification).

STEP 2

PREVIOUS LICENSES

List all individual or contractor electrical licenses you hold or have held in any state. Submit a copy of all out-of-state licenses with your application.

List license(s):

STEP 3	LICENSE TYPE

Please select a license type from the list below. Fees are nonrefundable.

The application instructions list the requirements and scope of each license.

STEP 4	TEST LOCATION

Please refer to the enclosed list or our Web site to choose a test location.

Reciprocal applicants do not test.

Preferred testing location:

Page 1 440-2570 (1/08/COM)

STEP 5

EMPLOYMENT HISTORY

List your experience in order, beginning with your present or most recent position. If more space is needed, attach additional sheets.

Please print

Employer’s name:

Period of employment:

Address:

From:

To:

Hours worked per week:

Phone:

(

)

Position/title:

Supervisor’s name:

Describe work performed:

Employer’s name:

Period of employment:

Address:

From:

To:

Hours worked per week:

Phone:

(

)

Position/title:

Supervisor’s name:

Describe work performed:

Employer’s name:

Period of employment:

Address:

From:

To:

Hours worked per week:

Phone:

(

)

Position/title:

Supervisor’s name:

Describe work performed:

Employer’s name:

Period of employment:

Address:

From:

To:

Hours worked per week:

Phone:

(

)

Position/title:

Supervisor’s name:

Describe work performed:

Applicant name:

440-2570 (1/08/COM)

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Electrical License Application

STEP 6

VERIFICATION OF WORK EXPERIENCE

To provide proof of your work experience, submit an Electrical Experience Verification form (440-2570A) from each of your employers.

OR

Applicants relying on military experience must submit the following:

•
 Official documentation from supervising official showing the type and approximate hours of work experience

•
 Other reliable documentation verifying training and experience if supervisor not located

STEP 7

PHOTOGRAPH OF APPLICANT

Applicants must submit a 2” x 2” passport-style photo. Write your name on the back of your photo and submit it with your application. This photo will be printed on your license when it is issued. Please do not staple the photo.

STEP 8

APPLICANT AFFIDAVIT

1.I hereby certify that, to the best of my knowledge, the information on this application is complete and correct.

2.I understand that my license may be suspended, conditioned, or revoked if I have deliberately falsified my application. ORS 455.125

3.I understand that, if I provide false information on this application or cheat on a licensing examination, my application will be denied and I may not apply for any license or be allowed to take any division-related examination for one year from the date of denial. OAR 918-001-0040

4.I certify that I have read these statements and understand the terms of my license.

Name (print):

Applicant signature:		Date:
STEP 9	CHECKLIST FOR APPLICANTS

				DEPARTMENT USE ONLY
	Approved		Signature:		Date:
	Denied		Signature:		Date:
Comments:

Apprentice applicants must provide proof of completion of a recognized apprenticeship program.

Applicant name:

440-2570 (1/08/COM)

Page 3

Electrical License Application

	Electrical Experience Verification	Mail verification to:
		Building Codes Division
	Department of Consumer & Business Services
		P.O. Box 14470
	Building Codes Division • 1535 Edgewater St. NW, Salem, Oregon
		Salem, OR 97309-0404
	Phone: (503) 373-1268 • Fax: (503) 378-2322 • TTY: (503) 373-1358
	Web: bcd.oregon.gov

Instructions: You must submit a separate experience verification form for each place of employment. If you are submitting more than one form, do not overlap dates of employment.

STEP 1

APPLICANT INFORMATION (please print)

Name (applicant):

Address:

City:

State:

ZIP:

Phone:

(

)

Fax: (

)

E-mail:

STEP 2

PERIOD OF EMPLOYMENT

Employer’s name:

Period of employment:

Address:

From:

To:

Hours worked per week:

Phone:

(

)

Applicant’s position/title:

STEP 3

VERIFIER INFORMATION

Applicants submitting verification of equivalent training and experience under OAR 918-030-0030(1)(c) must provide verification from the following persons:

• A current or previous employer actively involved with the applicant’s work;

• The individual who supervised the work if the current or previous employer is no longer in business, is deceased, or otherwise cannot be located; or

• A co-worker who was directly involved in the work performed, only if both the employer and the supervisor cannot be located. Co-worker verification must be accompanied by supporting documentation, such as employment records, showing that the verifier worked with the applicant and has knowledge of the work performed.

Name of verifier:

Address:						Phone: (		)
City:				State:			ZIP:
License number(s):
Verifier’s employment relationship to applicant:

440-2570A (7/06/COM/WEB)

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