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Get CA DLSE-ECF3 2012

Dir. ca.gov/dlse/ecu/ElectricalTrade. html Electrician Certification Program Phone 415 703-4919 ELECTRICIAN EXAM RETEST FORM Name Last Sfx First Initial Name must match U. S. Drivers License or State ID Drivers License or State ID D/L State Birthdate MM Please PRINT or type all information in INK DD YYYY Mailing Address City County State Zip Day Phone - E-Mail Evening Phone Retest Exam Language Selection check one English Spanish RETEST of Exam s Taken but Not Passed OR RETEST of Certification RENEWAL Exam Check Exam s not passed G R F V L Date s taken ECP Tracking Nbr s if known Attach Exam Fee of 100 per Exam. You must wait 60 days to retest an examination. G General R Residential F Fire/Life Safety V Voice Data Video L Nonresidential Lighting Date s scheduled Attach a Processing Fee of 75 PLUS an Exam Fee of 100 per Exam. Any retest must be taken within 1 year from the date of notification of eligibility to take the original examination. I certify under penalty of perjury that all statements and attachments are true and correct. State of California Department of Industrial Relations Division of Labor Standards Enforcement www. Signature Date Submit form with original signature and keep a copy for your records. Incomplete or inaccurately paid forms will NOT be approved* Exact payment by check or money order must be payable to DIR Electrician Certification Fund. Mail this completed form with all required attachments to Attn Electrician Certification Unit PO Box 420603 San Francisco CA 94142-0603 For Office Use Approved by Form DLSE-ECF3 09/2012. Signature Date Submit form with original signature and keep a copy for your records. Incomplete or inaccurately paid forms will NOT be approved* Exact payment by check or money order must be payable to DIR Electrician Certification Fund. Mail this completed form with all required attachments to Attn Electrician Certification Unit PO Box 420603 San Francisco CA 94142-0603 For Office Use Approved by Form DLSE-ECF3 09/2012. .

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