Electrical License Application Mail Application With .

Electrical License ApplicationDepartment of Consumer and Business ServicesBuilding Codes Division 1535 Edgewater St. NW, Salem, OregonPhone: 503-373-1268 Fax: 503-378-2322Web: oregon.gov/bcdMail application with payment to:DCBS Fiscal ServicesP.O. Box 14610Salem, OR 97309-0445Important: Read the application instructions before completing this form. Please complete all steps beforesubmitting your application and refer to the checklist at the end of this form.STEP 1APPLICANT INFORMATION (please print)LastFirstName:Address (street or P.O. Box):City:Phone:-Fax:Middle initialState:--–Social Security number (Required, ORS 25.785):ZIP:Email:–Your Social Security number is required for BCD licenses, certifications, and registrations according to ORS 25.785, ORS 305.385, 42USC § 405 (c)(2)(C)(i), and 42 USC § 666(a)(13). Failure to provide this information will be basis for application refusal. Your SSN maybe shared with other authorities only for tax-administration purposes and child-support enforcement (including identification).STEP 2PREVIOUS LICENSESList all individual or contractor electrical licenses you hold or have held in any state. Submit a copy of all out-of-state licenseswith your application.List licenses:STEP 3LICENSE TYPEPlease select a license type from the list below. Fees are nonrefundable.The application instructions list the requirements and scope of each license.General supervising electrician (S) 100.00General journeyman (J) 100.00Limited supervising electrician (PS) 100.00Limited journeyman manufacturing plant (PJ) 100.00Limited energy technician Class A (LEA) 50.00Limited energy technician Class B (LEB) 50.00Limited maintenance electrician (LME) 100.00Limited residential electrician (LR) 100.00Limited journeyman sign electrician (SIG) 50.00Limited journeyman stage electrician (ST) 50.00Limited building maintenance electrician (BME) 50.00Limited renewable energy technician (LRT) 50.00STEP 4TEST LOCATIONPlease refer to the enclosed list or our Web site to choose a test location.Reciprocal applicants do not test.Preferred testing location:Make check or money order payable to Department ofConsumer & Business Services. If paying by credit card,applicant must sign credit card information box. Do notsend cash.VisaMasterCardDiscoverPhone:-Secure fax forcredit card payments:503-947-2333Fee varies based on license type.DCBS Fiscal use only: 12104/0600- Cardholder signatureAmountName of cardholder as shown on credit card/Credit card number440-2570 (08/19/COM)Expiration datePage 1Electrical License Application

STEP 5EMPLOYMENT HISTORYList your experience in order, beginning with your present or most recent position. If more space is needed, attach additional sheets.Please printEmployer’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 (08/19/COM)Page 2Electrical License Application

STEP 6VERIFICATION OF WORK EXPERIENCETo provide proof of your work experience, submit an Electrical Experience Verification form (440-2570A) from each of youremployers.ORApplicants 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 locatedSTEP 7PHOTOGRAPH OF APPLICANTApplicants must submit a 2-inch by 2-inch passport-style photo. Write your name on the back of your photo and submit it withyour application. This photo will be printed on your license when it is issued. Please do not staple the photo.STEP 8APPLICANT AFFIDAVIT1. 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 455.1253. I understand that, if I provide false information on this application or cheat on a licensing examination, my applicationwill be denied and I may not apply for any license or be allowed to take any division-related examination for one yearfrom the date of denial. OAR 918-001-00404. I certify that I have read these statements and understand the terms of my license.Name (print):Applicant signature:STEP 91.2.3.4.Date:CHECKLIST FOR APPLICANTSApplication form completed (Form 440-2570).Affidavit signed and dated (Step 8 on application).Verification of work experience (Form 440-2570A) from each employer.Additional documentation:Proof of completion of an Oregon-approved apprenticeship or training programProof of completion of an out-of-state apprenticeship program recognized by the state of OregonOfficial transcripts of classroom training5.6.7.Proof of a high school diploma, GED, or equivalent. A college degree will substitute.Passport-style photo (2-inch by 2-inch) with applicant’s name on the back.Payment of fee.DEPARTMENT USE mments:Apprentice applicants must provide proof of completion of a recognized apprenticeship program.Applicant name:440-2570 (08/19/COM)Page 3Electrical License Application

Electrical Experience VerificationDepartment of Consumer and Business ServicesBuilding Codes Division 1535 Edgewater St. NW, Salem, OregonPhone: 503-373-1268 Fax: 503-378-2322 TTY: 503-373-1358Web: oregon.gov/bcdMail verification to:Building Codes DivisionP.O. Box 14470Salem, OR 97309-0404Instructions: You must submit a separate experience verification form for each place of employment. If you aresubmitting more than one form, do not overlap dates of employment.STEP 1APPLICANT INFORMATION (please print)Name (applicant):Address:City:State:Phone:--STEP 2Fax:--ZIP:Email:PERIOD OF EMPLOYMENTEmployer’s name:Period of employment:Address:From:To:Hours worked per week:Phone:-STEP 3Applicant’s position/title:-VERIFIER INFORMATIONApplicants submitting verification of equivalent training and experience under OAR 918-030-0030(1)(c) must provideverification 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 supervisorcannot be located. Co-worker verification must be accompanied by supporting documentation, such asemployment records, showing that the verifier worked with the applicant and has knowledge of the workperformed.Name of verifier:Address:City:Phone:State:--ZIP:License numbers:Verifier’s employment relationship to applicant:440-2570A (08/19/COM)Page 1Electrical License Application - Verification

Applicant (print name):STEP 4VERIFIED EXPERIENCE1. Enter the type of license you are applying for:2. From license types on Page 3, choose the categories in which you have work experience and enter them under“Category.” (See example, below.)3. Under “Total hours,” enter the hours of work experience in each category. The division will consider no more than2,000 hours of experience per year. OAR 918-282-0030(4).4. Enter your specific work duty experience under “Description of duties.” If you need more information, seeoregon.gov/bcd, “Statutes and Rules,” “Oregon Administrative Rules,” click on 918-282, then scroll down to thedesired license type.5. Make copies of this page, if needed.CategoryTotal hoursDescription of duties(example) Residential wiring2000Installations, wire pulling, service and panel, conduit, flex, metalromex boxes, electrical heating systemsSTEP 5VERIFIER CONFIRMATIONAs the verifier of the preceding information, I confirm that it is true and correct to the best of my knowledge.Verifier name (please print):Verifier signature:440-2570A (08/19/COM)Date:Page 2Electrical License Application - Verification

ELECTRICAL WORK EXPERIENCE CATEGORIESGeneral journeyman (J)General supervisor (S)Limited residential (LR) Stockroom, materials handling Residential wiring Commercial installations Industrial installations Troubleshooting and maintenance Finishing and fixture hanging Signal and control systems Remodeling Underground constructionLimited supervisor (PS)Limited plant journeyman (PJ)Limited maintenance electrician (LME) Electrical circuits Motors and generators Controls, manual and automatic Troubleshooting In-place motor cleaning Lighting Electrical drawingsLimited journeyman sign (SIG) Stockroom, materials handling Pattern and blueprints Layout design Assembly of display Display painting and component parts Display installation, service, and maintenance Transportation and hoisting equipmentmaintenance and repairLimited energy, Class A (LEA)Limited energy, Class B (LEB) Protective signaling (fire alarm, nurse call, burglaralarm, security and voice evacuation systems that arepart of a fire or life safety system) (LEA only) HVACMedicalBoiler controlsIntercom, paging, sound, CCTVClock systemsData , materials handling, shop and serviceLimited energy wiring: installations, wire pulling,splices, conduit, flex, tray and duct, control panelsand controls, wiring devices, removal and finish work Troubleshooting and maintenance Outdoor installations, overhead and underground Occupation or trade-specific training related to licenseLimited building maintenance (BME) Electrical appliances Light switches Light fixtures Fans Receptacles Fluorescent ballastsLimited renewable energy technician (LRT)Available only by completing an OregonapprenticeshipLimited journeyman stage (ST) Stage/film and video/event lighting Stage/film and video dimmer distribution Three-phase temporary power distribution Stage/film and video lamp operator Stage/film and video/event propertyTo see a detailed list of minimum hourly requirements for each category, go to our website, oregon.gov/bcd, “Statutesand Rules,” “Oregon Administrative Rules,” click on 918-282, then scroll down to the desired license type.440-2570A (08/19/COM)Page 3Electrical License Application - Verification