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									                                                  State of California
                                         Department of Industrial Relations
                                        Division of Apprenticeship Standards
                                    Electrician Certification Program

                           APPLICATION FOR    NEW REGISTRATION OF
                                    = ELECTRICIAN TRAINEE =
Name: Last:                                                            Sfx:       First:                           Initial:
Other names as Electrician within previous 5 years:
Drivers License or State ID #:                                           D/L State:     CA   Birthdate:       /        /
                                                                                                      MM      DD           YYYY
                                        Please PRINT or type all information in INK
Mailing Address:
       City:                                                              County:
       State:     CA       Zip:                     -
       Day Phone:                   /               -                     Evening Phone:                  /        -

[Optional]                     Current Electrical Employer (if any) to complete this box:
I attest under penalty of perjury that this Electrician Trainee shall be under the direct supervision of an electrician
certified pursuant to Section 3099 who is responsible for supervising no more than one Electrician Trainee.
  Employer Name (signature):
  Employer Name (printed):
  C.S.L.B. C10 License No.:             |                          |

  Company Name:
  Company Address:
  City:                                                                       State:               Zip:            -
  Phone No.:               /                -

                               Electrician Trainee to enter school number and name:
I certify that I am enrolled in the Approved Curriculum of classwork at: School No.:                 109
School Name (printed): EDEN Area ROP/Construction Craft Training Center
                           Attach copies of the Enrollment forms in an Approved Curriculum

Attach exact payment of $25.00 by check or money order payable to ‘DIR – Electrician Certification Fund’.
               This registration must be renewed annually until you become certified or leave the trade.

Signature:                                                                                   Date:
          I certify under penalty of perjury that all statements and attachments are true and correct.
                                        See page 2 for instructions and mailing address.

(For Office Use) Trainee No.: T -                                         Page 1 of 2             Form DAS-ECF4 (11/2005)7
                                              State of California
                                     Department of Industrial Relations
                                    Division of Apprenticeship Standards
                                    Electrician Certification Program

                               INSTRUCTIONS FOR COMPLETING THIS FORM

Electrician Trainee:
         Complete the whole form except the Current Electrical Employer box.
         Enter all your information in the top areas. If you are currently working for a C10 electrical contractor,
              enter their information in the Company Name box. Be sure the C.S.L.B. C10 License No. is correct.
         Print both the School Number and School Name of the Approved School. You cannot register without
              school information and copies of their forms.
         Sign and date this form. Attach your check or money order for $25.00. Attach a copy of your school
              enrollment form. Make copies for your records. Mail the application form, check/money order, and
              school enrollment forms to the address at the bottom of this page.

Current Electrical Employer:
         Sign and print your name in the [Optional] Current Electrical Employer box. This attests that you will
              follow the regulation regarding the supervision of Electrician Trainees.
         Enter your C.S.L.B. C10 License No. where requested.

                    Keep a copy of this signed application and all attachments for your records.
                         Incomplete or inaccurately paid applications will NOT be approved.
                               Mail this completed form with all required attachments to:
                                       Division of Apprenticeship Standards
                                         Attn: Electrician Certification Unit
                                                   PO Box 420603
                                          San Francisco, CA 94142-0603

(For Office Use) Trainee No.: T -                               Page 2 of 2              Form DAS-ECF4 (11/2005)7

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