APPLICATION FOR AN APPRENTICE ELECTRICIAN REGISTRATION

							                 APPLICATION FOR AN APPRENTICE ELECTRICIAN REGISTRATION
                 NORTH DAKOTA STATE ELECTRICAL BOARD
                 SFN 11857 (Rev. 07-2000)                                                                     NORTH DAKOTA STATE ELECTRICAL BOARD
                                                                                                                           P.O. BOX 7335
                                                                                                                       BISMARCK, ND 58507

$10.00 REGISTRATION FEE MUST ACCOMPANY THIS APPLICATION
Date                               Social Security No.                        Name                                                 Telephone


Mailing Address (Street or P.O. Box No.)


City                                                                          County                                 State         Zip Code


Date of Birth                      How many years have you been a                               Education: Circle Highest Grade Completed
                                   resident of the State of North Dakota?                               1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Are you a graduate of an Electrical Trade School?
    No         Yes--List name and address of school
State other courses of Electrical study or approved apprenticeship training, if any




Name of above course                                                          Address


Instructor


Have you previously been registered with the North Dakota State Electrical Board?
    No         Yes


                                                                  EMPLOYMENT RECORD
Instruction for Completion: List complete street and city address for each employer, list exact dates of employment for each employer, reason for separation.
The Board will verify all employment data with present and former employers.
Name of Present Employer                                                                                                           Date Started


Street Address                                                                City                                   State         Zip Code


Employed in what capacity?


Describe work




Master Electrician under whom you will be serving your apprentice


Signature of Master Electrician Presently Serving Under                       Title




                                        APPLICANT MUST SIGN APPLICATION ON REVERSE SIDE
                              All spaces provided must be completed. If question does not apply write "none" in space.

                         The North Dakota State Electrical Board will provide this form in an alternate format upon request.
APPLICATION FOR APPRENTICE ELECTRICIAN REGISTRATION
SFN 11857 (Rev. 07-2000) Page 2
                                                      EMPLOYMENT RECORD - Continued
Name of Previous Employer                                                                      Date Started   Date Left


Street Address                                                            City                                State


Employed in what capacity?


Reason for Leaving?


Describe work




Name of Previous Employer                                                                      Date Started   Date Left


Street Address                                                            City                                State


Employed in what capacity?


Reason for Leaving?


Describe work




Remarks or other information




I do solemnly swear that the statements made herein are correct to the best of my knowledge.
Applicant's Signature




                                     SPACE BELOW RESERVED FOR STATE ELECTRICAL BOARD