Fillable Printable Form 626-001-000
Fillable Printable Form 626-001-000
Form 626-001-000
F626-001-000 Application for Electrical Examination 01-2017 GL 1250 Index: APP
Electrical Licensing and Certification
PO Box 44460
Olympia WA 98504-4460
www.Lni.wa.gov/Electrical
Application for Electrical Examination
Attached is the State of Washington application for the journey level or specialty electrician’s certificate examination.
To avoid delays in the processing of your application, please ensure that you have included all of the items on the
checklist provided below. Applications received without all the information will be denied.
Complete the entire application including the work history portion.
Date and sign the application in the Applicant’s Signature block.
Include the $90.00 fee. Make checks payable to: Department of Labor and Industries.
Supply original Affidavits of Experience unless already on file with the Department.
Notes:
• Verification of your experience must be submitted on an Affidavit of Experience form and must be notarized.
The Affidavits of Experience form must be completed by:
o An authorized representative for the electrical contractor or
o Your Training Director if you are enrolled in a formal apprenticeship program.
• See RCW 19.28 and WAC 296-46B-945
for additional information on qualifying for the Washington electrician
examination.
• To be accepted, all experience must have been legally obtained under the requirements of RCW 19.28 or as
required in the state where the electrical work was performed. See WAC 296-46B-945.
• No self-verification of electrical training experience will be accepted.
• Washington hours will not be credited if you did not have a current electrical training certificate.
RCW
19.28.161(2) is very clear that you must have an electrical training certificate to learn the electrical trade.
• All General Journey level applicants must have 8,000 hours of experience with at least 4,000 of that being in
new commercial/industrial installation.
• All Residential, Pump & Irrigation, Sign, Limited Energy, HVAC/Refrigeration, and Nonresidential Maintenance
Specialty Electrician applicants must have 4,000 hours of experience in the appropriate specialty.
• All Domestic Well, HVAC/Refrigeration – Restricted, Nonresidential Lighting Maintenance & Retrofit, Residential
Maintenance, Restricted Nonresidential Maintenance, Appliance Repair, Equipment Repair, and Door, Gate, &
Similar Systems Specialty Electrician applicants must have 2,000 hours of experience in the appropriate
specialty. (See WAC 296-46B-945
& Table 945-1 for important information.)
• Out of state electricians must provide evidence that they meet the requirements of RCW 19.28.191 and provide
evidence of that as defined in WAC 296-46B-945. Please contact Electrical Licensing at 360-902-5269 before
coming to Washington to get details about what is acceptable evidence of experience. You should send the
completed application, fee, and evidence of experience via express mail. Then if approved, you should take the
exam before coming to Washington. Waiting to do any of the above until you have arrived in Washington may
delay your ability to quickly go to work as an electrician.
• You will be notified by mail if your application is approved or denied. If your application is approved, the
department will mail your approval letter with the contact information for the exam contractor. A separate fee
scheduling your examination must be paid directly to the exam contractor. You will be responsible for scheduling
your examination with the exam contractor. You can obtain information to study for the examination on the
electrical website under Exam Information.
• Allow at least 4 weeks processing time under normal circumstances.
• Once you successfully pass the examination the department will mail your certificate to you within approximately
2 – 4 weeks.
• You must keep you electrical training certificate current until you pass the examination. If you take and pass a
specialty electrician examination, you will also need to maintain your electrical training certificate if you work
outside the scope of that specialty. (Example: You have a residential electrician certificate but you want to work
on a commercial job; you must have an electrical training certificate and work under the proper supervision.)
F626-001-000 Application for Electrical Examination 01-2017 GL 1250 Index: APP
Electrical Licensing and Certification
PO Box 44460
Olympia WA 98504-4460
www.Lni.wa.gov/Electrical
Application for Electrical Examination
Enclose a check or money order payable to Department of Labor and Industries for $90.00.
Note: A separate fee for administering the examination must be paid directly to the exam contractor.
Applicant Information
Name (Last, First, Middle Initial)
Date of Birth
Mailing Address
Social Security Number (for ID only)
City
State
Zip Code
Daytime Phone (include area code)
Join the Electrical listserv for email updates and notices by giving your email address here
I am applying for the Electrical Examination for the certificate type checked below:
(See WAC 296-46B-920
for scope-of-work details)
(01) General
(07) Nonresidential Maintenance
(02) Residential (07A) Nonresidential Lighting Maintenance &
Retrofit
(03) Pump and Irrigation
(07B) Residential Maintenance
(03A) Domestic Well
(07C) Restricted Nonresidential Maintenance
(04) Signs
(07D) Appliance Repair
(06) Limited Energy System
(07E) Equipment Repair
(06A) HVAC/Refrigeration Limited Energy System
(10) Door, Gate, and Similar Systems
(06B) HVAC/Refrigeration – Restricted
Select “Yes” or “No” to the following questions:
Have you previously been a certified electrician or trainee with this agency?
Yes No
Is this your first application for an electrician exam certificate with this agency?
Yes No
Are all of your affidavits of experience already on file with the department?
Yes ― you do not have to submit additional affidavits of experience.
No ― you must submit additional affidavits of experience.
All applications and documents submitted must be originals and become the property of the department.
F626-001-000 Application for Electrical Examination 01-2017 GL 1250 Index: APP
Employment History
Name of Employer
Start Date
End Date
Address
City
State
Zip Code
Position – Job Duties
Name of Employer
Start Date
End Date
Address
City
State
Zip Code
Position – Job Duties
I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and
correct.
Applicant’s Signature
Date
For L&I Use Only
Approved:
Yes
No
Reason Code
Cross-Ref with Prev. Certificate #
A/C
Initials
Date
E
R
RESET
F500-043-000 Affidavit of Experience for 75% Supervision Specialties 01-2017 GL 1355 Index: AFF
Electrical Licensing and Certification
PO Box 44460
Olympia WA 98504-4460
www.Lni.wa.gov/Electrical
Affidavit of Experience for 75%
Supervision Specialties
(Time frame cannot exceed 24 months per affidavit)
Update Fee of $53.40 required if not submitted with renewal
Please read this information before completing the affidavit form.
• There can be no errors, whiteouts, alternations, or additions on this form. You must submit the original
copy. Please print clearly.
• The department cannot credit hours worked during any times that the electrical training certificate or
electrical contractor license were not active. Don’t report any such hours on the affidavit. Each time frame
requires a separate affidavit.
• An affidavit needs to be filled out for each continuous time frame of hours worked. If the trainee stops doing
electrical work for any period of time, that time frame ends and a new begins. Each time frame requires a
separate affidavit.
• See WAC 296-45B-290
about scope-of-work for electrical specialties. All training hours must be separated
and submitted in the proper category.
• Work in the specialty categories requires supervision by a journey level or specialty electrician in a ratio to
1 electrician to 2 trainees.
• If the experience is from out of state, you must provide verification of your experience as defined in
WAC
296-46B-945(7-10).
• Electrical training hours gained in specialties requiring less than 4,000 (2 years) for certification may not be
credited toward qualification for journey level electrician. See WAC 296-46B Table 945-1
for detail.
F500-043-000 Affidavit of Experience for 75% Supervision Specialties 01-2017 GL 1355 Index: AFF
Affidavit of Experience for 75%
Supervision Specialties
I,
affirm and certify that
Print name of Administrator/Master Electrician, Authorized Electrical Contractor’s Representative or Approved Training Director
has worked in Washington as an employee of
Print Name of Trainee
Training Certificate or Social Security Number
performing electrical installations inspected
Print Name of Company or Training Program
UBI or License Number
under RCW 19.28 continuously from
to
Month Day Year
Month Day Year
with 75% direct supervision under a Washington certified journey level, master, or specialty electrician, in the category
and number of hours below.
Hours
Category
Hours
Category
(01)
General Commercial/New Industrial
(06)
Limited Energy System
(02)
Residential
(06A)
HVAC/Refrigeration Limited Energy
(03)
Pump and Irrigation
(07)
Nonresidential Maintenance
(04)
Signs
Signature ― Sign in the presence of a notary
I hereby certify that the information on this affidavit is true and accurate. I acknowledge that the department may issue
citations for false statements or material misrepresentation per RCW 19.28 and WAC 296-46B.
Signature of Administrator/Master Electrician, Authorized Electrical Contractor’s or Approved Training Director
Date
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
I hereby certify that the information on this affidavit is true and accurate and request that these hours be credited to my
electrical training file. I acknowledge that the department may deny this affidavit, issue citation, and subtract up to 2000
hours from my total hours of experience, if I make a false statement or misrepresent the hours on this affidavit per RCW
19.28 and WAC 296-46B.
Signature of the Applicant
Date
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
For L&I Use Only
Approved:
Yes No
Reason Code
Lapse From
Lapse To
A/C
Initials
Date
RESET
F500-137-000 Affidavit of Experience for 100% Supervision Specialties 01-2017 GL 1355 Index: AFF
Electrical Licensing and Certification
PO Box 44460
Olympia WA 98504-4460
www.Lni.wa.gov/Electrical
Affidavit of Experience for 100%
Supervision Specialties
(Time frame cannot exceed 24 months per affidavit)
Update Fee of $53.40 required if not submitted with renewal
Please read this information before completing the affidavit form.
• There can be no errors, whiteouts, alternations, or additions on this form. You must submit the original
copy. Please print clearly.
• The department cannot credit hours worked during any times that the electrical training certificate or
electrical contractor license were not active. Don’t report any such hours on the affidavit. Each time frame
requires a separate affidavit.
• An affidavit needs to be filled out for each continuous time frame of hours worked. If the trainee stops doing
electrical work for any period of time, that time frame ends and a new begins. Each time frame requires a
separate affidavit.
• See WAC 296-45B-290
about scope-of-work for electrical specialties. All training hours must be separated
and submitted in the proper category.
• Work in the specialty categories requires supervision by a journey level or specialty electrician in a ratio to
1 electrician to 2 trainees.
• If the experience is from out of state, you must provide verification of your experience as defined in
WAC
296-46B-945(7-10).
• Electrical training hours gained in specialties requiring less than 4,000 (2 years) for certification may not be
credited toward qualification for journey level electrician. See WAC 296-46B Table 945-1
for detail.
F500-137-000 Affidavit of Experience for 100% Supervision Specialties 01-2017 GL 1355 Index: AFF
Affidavit of Experience for 100%
Supervision Specialties
I,
affirm and certify that
Print name of Administrator/Master Electrician, Authorized Electrical Contractor’s Representative or Approved Training Director
has worked in Washington as an employee of
Print Name of Trainee
Training Certificate or Social Security Number
performing electrical installations inspected
Print Name of Company or Training Program
UBI or License Number
under RCW 19.28 continuously from
to
Month Day Year
Month Day Year
with 100% direct supervision under a Washington certified journey level, master, or specialty electrician, in the category
and number of hours below.
Hours
Category
Hours
Category
(03A)
Domestic Well
(07C)
Restricted Non-Residential Maintenance
(6B)
HVAC/Refrigeration – Restricted
(07D)
Appliance Repair
(07A)
Non-Residential Lighting Maintenance
(07E)
Equipment Repair
(07B)
Residential Maintenance
(10)
Door, Gate, and Similar Systems
Signature ― Sign in the presence of a notary
I hereby certify that the information on this affidavit is true and accurate. I acknowledge that the department may issue
citations for false statements or material misrepresentation per RCW 19.28 and WAC 296-46B.
Signature of Administrator/Master Electrician, Authorized Electrical Contractor’s or Approved Training Director
Date
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
I hereby certify that the information on this affidavit is true and accurate and request that these hours be credited to my
electrical training file. I acknowledge that the department may deny this affidavit, issue citation, and subtract up to 2000
hours from my total hours of experience, if I make a false statement or misrepresent the hours on this affidavit per RCW
19.28 and WAC 296-46B.
Signature of the Applicant
Date
Subscribed and sworn to before me this date
Notary Seal or Stamp
Notary public signature
For the state of
Residing at
Title
My commission expires
For L&I Use Only
Approved:
Yes No
Reason Code
Lapse From
Lapse To
A/C
Initials
Date
RESET
