Fillable Printable Wireman Licence Application Form - Texas
Fillable Printable Wireman Licence Application Form - Texas
Wireman Licence Application Form - Texas
1. NAME – Write your legal name in the spaces provided. (Last, First, Middle Name, Suffix) Examples of a suffix in-
clude Jr., Sr., and III. (Mr. is not a suffix.)
2. DATE OF BIRTH – Write your birthdate.
3. GENDER – Select whether you are male or female.
4. SOCIAL SECURITY NUMBER – Social Security number disclosure is required by Section 231.302(1) of the Texas
Family Code in order to obtain a license. Your social security number is subject to disclosure to an agency authorized
to assist in th e collection of child support payments. F or more information regarding child support payments, contact
the Texas Attorney General at:
www.oag.state.tx.us/child/index or call (512) 460-6000 or (800) 252-8014.
5. MAILING ADDRESS – Write your current mailing address. This is the address where we will send you mail. A post
office box can be used as a mailing address. You can add the zip plus-4 to help the postal service deliver mail more
efficiently and accurately.
6. PHYSICAL ADDRESS – Write your physical address of your residence. Do not use a post office box for this ad-
dress.
7. PHONE NUMBER – Write a telephone number, including the area code, where we can reach you during the day.
This may be your office phone number where we can leave a message.
8. EMAIL ADDRESS – Write your email address. Please provide your email address so the department may email li-
cense information and required notices to you. Your email address is confidential pursuant to the Texas Public Infor-
mation Act, and the department will not share it with the public.
9. CRIMINAL HISTORY – Indicate if you have ever been convicted of, or placed on deferred adjudication for, any mis-
demeanor or felony, other than a minor traffic vio lation. If YES, complete and a ttach a Criminal History Questionnaire
for each offense. This form can be obtained from the TDLR website at www.tdlr.texas.gov/MISC/lic002.pdf
If you are worried your criminal history could prevent you from getting this license, Texas allows you to have your
criminal history evaluated before submitting your application and non-refundable fees. To request a criminal history
evaluation, submit a Criminal History Evaluation Letter, a completed Criminal History Questionnaire form for each
crime you were convicted of, or placed on deferred adjudication for, and a $25 fee. You can find more information on
the process and download the necessary forms on the TDLR website at www.tdlr.texas.gov/crimHistoryEval.htm
10. DISCIPLINARY ACTION HISTORY – Indicate if you have ever had an occupational license, certification, or
registration suspended, revoked, or denied in any state. If you have, complete and attach a Disciplinary
Action Questionnaire for each disciplinary action. This form can be obtained from the TDLR website at
www.tdlr.texas.gov/misc/Di sciplinary Action Questionnaire.pdf
11. LICENSING REQUIREMENTS - You must have at least 4,000 hours of on-the-job training under the supervision of
a master electrician or residential wireman prior to taking the exam. When your experience has been approved, PSI
will mail you a postcard with information on how to schedule your exam. The employment history portion of the appli-
cation must include the full 4,000 hours. An Experience Verification Form is required for each employer and must be
signed by the supe rvising master electrician or su pervising residential wireman.
The application must be completed and signed by the applicant. An application is not considered com plete and will not be proce ssed
until all required items have been submitted. All information provided must be typed or printed in black ink. Attachments must be
submitted on separ ate pieces of single -sided, 8½” x 11” paper. use a paperclip to fasten all pages to gether, with the check or money
order on top. Do not use staples. Make check or money order payable to TDLR.
DOCUMENTS SUBMITTED WITH YOUR APPLICATION WILL NOT BE RETURNED. KEEP A COPY OF YOUR COMPLETED
APPLICATION, ALL ATTACHMENTS, AND YOUR CHECK OR MONEY ORDER.
RESIDENTIAL WIREMAN LICENSE APPLICATION INSTRUCTIONS
PO Box 12157 Austin, T exas 78711-2157
(800) 803-9202 (512) 463-6599 FAX (512) 475-2871
12 MILITARY SERVICE MEMBERS, VETERANS AND MILITARY SPOUSES - Check this box if you intend to use mili-
tary service, experience, training or education or are applying as a military spouse.
Military Service Members or Military Veterans - Submit documentation that provides verifiable proof of your rele-
vant military service, experience, training or education. Documents that can be submitted are your DD-214,
VMET-2586, military transcripts, training records, evaluation reports or a letter from your commanding officer
describing your rel evant duties and training.
Military Spouses - Submit a completed Military Spouse Supplemental Application with this application and all
other requested information. The Military Spouse Supplemental Application can be found at
www.tdlr.texas.gov/misc/militaryspouse.pdf
13. STATEMENT OF APPLICANT - Carefully read the statement of applicant before you sign and date your application.
14. EMPLOYMENT HISTORY - If you are applying for licensure by experience and exam, you will need to complete all
portions of the employment history indicating your 4,000 on-the-job training hours under the supervision of a master
electrician or residential wireman. All areas of this document must be completed.
15. EXPERIENCE VERIFICATION - An Experience Verification Form or letters on company letterhead must be com-
pleted and signed by the supervising master electrician or residential wireman. This form along with the Employ-
ment History portion of the application must match. Make additional copies of the experience verification form as
needed.
If you are licensed as a residential wireman by a municipal o r re gional licensing authority, you do not need to
provide any experience with this application. Include a copy of your resi dential wireman license issued by the
municipal or regional licensing authority. You must also include the Discontinued Municipal or Regional Licensing
Program Form.
State law prohibits renewing a license more than once after a licensee has defaulted on a student loan guaranteed by
the Texas Guaranteed Student Loan Corporation (TGSLC) unless the licensee has entered into a repayment agreement
with TGSLC. YOU SHOULD CONTACT TGSLC BEFORE FILING THIS APPLICATION if you have defaulted on a stu-
dent loan. An application or renewal may be rejected if this agency has received information from TGSLC that the appli-
cant has defaulted on a student loan. The Texas Guaranteed Student Loan Corporation can be contacted at: Texas
Guaranteed ATTN: Collections PO Box 83100, Round Rock, TX 78683-3100, Telephone: (800) 222-6297.
10. Have you ever had an occupatio nal license, certification
or registration suspended, revoked, or denied in any
state?
If YES, attach a Disciplinary Action Questionnaire to this application.
(This does not include your driver license.)
You must submit this completed application to TDLR before scheduling your Texas examination. If your applica-
tion is approv ed, we will contact the exam provider (PSI) and they will send you a postcard to schedule your
Texas exam.
YOU MUST MEET ALL REQUIREMENTS WITHIN TWELVE MONTHS OF THE FILING DATE, OR THE APPLICATION WILL BE
TERMINATED.
APPLICATION FEE: $20 (FEE IS NON-REFUNDABLE)
Page 1 of 4
TDLR Form ELC013 rev Janua ry 2015
RESIDENTIAL WIREMAN LICENSE APPLICATION
PO Box 12157 Austin, T exas 78711-2157
(800) 803-9202 (512) 463-6599 FAX (512) 475-2871
Yes No
9. Have you ever been convicted of, or placed on deferred adjudication for, any
misdemeanor or felony, other than a minor traffic violation?
If YES, complete and attach a Criminal History Questionnaire for each offense.
See instruction sheet for more information
Yes No
2. Date of Birth:
____________ - ____ _____ - ____________
Month Day Year
3. Gender:
Male Female
4. Social Security Number:
(See instruction sheet for disclosure information) ______ ______ ______ _____ _____ ______ ______ ______ ______
Number, Street Name, Suite Number/Apartment Number
City State Zip Code
5. Mailing Address: (PO box can be used for this address)
7. Phone Number: 8. Email Address:
(______) ______________________
Area Code Phone Number
Email address (ex: [email protected]) (See Instruction sh eet for disclosure information)
Number, Street Name, Suite Number/Apartment Number
City State Zip Code
6. Physical Address: (PO box cannot be used for this address)
1. Name:
__________ _____________________________ ________ _________________ ___________ _______ ____
Last First Middle Suffix
13. STATEMENT OF APPLICANT
I certify that I have read and will comply with all applicable provisions of the Electrician Act; Texas Occupation Code, Chapter 1305
and Chapter 51;T exas Administrative Code, Chapter 60; and the Electricia ns Administrative Rules, Texas Administrativ e Code, Chap-
ter 73. I understand that prov iding false information on this application may result in de nial of this application and/or revocation of the
license I am requesting a nd the imposition of administrative pena lties.
_______________________________ _____________________ ___________________ __________ _________
Date Signed Signature of Applicant
Page 2 of 4
TDLR Form ELC013 rev Janua ry 2015
11. LICENSE REQUIREMENTS
To qualify for a Residential Wireman License, you must meet either A or B below:
A.
Passed the Texas Residen tial Wireman Exam
Completed at least 4,000 hours of on-the-job training under the supervision of a master ele ctrician or residential
wireman.
Note: Completed appli catio n must include the Experience Verification Form (o r letters from previous supervisors)
and the Employment History portion of the application. The Experience Verification Form, or letters must match
the information in the Employment History se ction of this application.
B.
Held a residential wire man license issued by a Texas municipality or region that has electe d to
discontinue issuing or rene wing licenses.
Held the municipal or regional license for the preceding year.
Submit your application within 90 days of the date the munici pality or region stops issuing or renewing
licenses.
Note: The Discontinued Municipal or Regional Licen sin g Program Form must be completed and attached to this
application.
12. MILITARY SERVICE MEMBERS, VETERANS & MILITARY SPOUSES
Check this box if you intend to use military service, experience, training or education or are applyi ng
as a military spouse.
*For military service, experience, training or education, attach to your application the supporting documenta-
tion
(DD-214, military transcripts, training records, VMET 2586, evaluation rep orts or a letter from your commanding
officer) that verifies relevant experience, service, training or educa t ion.
14. EMPLOYMENT HISTORY
Name: (As it appears on your original application)
__________ _____________________________ ________ _________________ ___________ ______ _____
Last First Middle Suffix
Social Security Number:
(See instruction sheet for disclosure information) ______ ______ ______ _____ _____ ______ ______ ______ ______
Describe job duties perfo rmed:
Employer Name:
Employer’s Phone Number:
Employer’s Address:
_______________________________________________________
Number, Street Name, Suite Number
___________________________________________________________________________________
City State Zip Code
Master Electrician/Residential Wireman’s Name:
Master Electrician/Residential Wireman’s
License Number and Is suing Jurisdiction:
______________ ____________________________ _________
License Number Issuing Jurisdiction
Dates of Employment:
From:____________________ To: ____________________
(Month/Day/Year) (Month/Day/Year)
Total Years or Hours of Experience:
Page 3 of 4
TDLR Form ELC013 rev Janua ry 2015
Describe job duties perfo rmed:
Employer Name:
Employer’s Phone Number:
Employer’s Address:
_______________________________________________________
Number, Street Name, Suite Number
___________________________________________________________________________________
City State Zip Code
Master Electrician/Residential Wireman’s Name:
Master Electrician/Residential Wireman’s
License Number and Is suing Jurisdiction:
______________ ____________________________________ _
License Number Issuing Jurisdiction
Dates of Employment:
From:____________________ To: ______ ___ _____ __ __ __
(Month/Day/Year) (Day/Month/Year)
Total Years or Hours of Experience:
Indicate below your employment history for each em ployer. You can make additional copies of this form and attach them if needed.
For each employment period, you must provide either a letter from the master electrician or residential wireman who supervised your on-the-job train-
ing or a completed Experience Verification Form. The Department may contact your licensed supervisor for verification.
Page 4 of 4
TDLR Form ELC013 rev Janua ry 2015
THIS FORM MUST BE COMPLETED BY A PERSON QUALIFIED TO VERIFY ELECTRICIAN EXPERIENCE WHOM THE
DEPARTMENT MAY CONTACT FOR VERIFICATION
Applicant’s Name:
___________ ____________________________ _______________________ __ ___________ ___________
Last First Middle Initial Suffix (JR, SR, III)
Master Electrician/Residential Wireman Name :
___________ ____________________________ _______________________ __
Last First
Phone Number:
(_______) _____ ___________
Area Code Phone Number
Company Nam e:
___________ _______________ _______________ ______________ _______________ _______________ ______
Your Electrician License Information: (Copy or letter of verification required)
__________________________________ __________________________________ _________________________________ ____________________________________
License Type (Journeyman, etc.) License Number Effective Date Expiration Date
State, County, or Municipality Issuing License:
Period You Supervised Applicant:
________________________________________ To ______________________________________
Start Date (Month/Day/Year) End Date (Month/Day/Year)
Did you supervise the electrical
work of the applicant d uring the
above dates ?
Yes
No
Did the applicant hold a valid license during the dates listed
above?
If YES, what was the license type?
________________________________________
Yes
No
Choose the correc t type of work performed by this applicant:
STATEMENT OF SUPERVISOR
TEXAS LICENSED EMPLOYER STATEMENT: As a licensee of The Texas Department of Licensing and Regulation, I have
only verified actual experience (number of hours and duties) that this applicant received while working under m y license and direct
supervision. I understand that I may be subject to disciplinary action up to and including revocation of my license if I verify experience
other than that which was performed while the applicant was working unde r my license and supervision.
BY SIGNING THIS FORM, I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT.
________________________ _______ _________________ _________ __________ _________ __________ ________
Date Signed Signature of Supervising Electrician
Detailed Description of work performed:
15. ELECTRICIAN EXPERIENCE VERIFICATION FORM
TEXAS DEPARTMENT OF LICENSING AND REGULATION
PO Box 12157 Austin, Texas 78711
(800) 803-9202 (512) 463-6599 FAX (512) 475-2871
www.tdlr.texas.gov [email protected]v
Residential Commercial Industrial Exempt Other
Installed Electrical Wiring System
Residential Commercial Industrial Exempt Other
Maintained Electrical Wiring System
Residential Commercial Industrial Exempt Other
Extended an Electrical Wiring System
Residential Commercial Industrial Exempt Other
Serviced Entrance Conductors
