Fillable Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 78780 Office Location: 4822 Madison Yards Way
Milwaukee, WI 53293-0780 Madison, WI 53705
FAX #: (608) 267-0592 E-Mail: DSPSCredTrades@wi.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
INSTRUCTIONS FOR REGISTERED ELECTRICIAN APPLICATION
Requirements for Credential
Per Wis. Stats. § 101.862, no person may install, repair or maintain electrical wiring unless the person is licensed as an Electrician by the Department
or unless the person is enrolled as a registered Electrician by the Department.
A Registered Electrician is not required to hold an Electrical Apprentice registration in conjunction with this license.
Per Wis. Admin. Code § SPS 305.40, a person who holds a registration as a registered Electrician shall perform electrical wiring activities under
the direct supervision of a person who holds a license either as a licensed Master Electrician or a licensed Journeyman Electrician.
Registered Electricians may perform electrical wiring activities under the direct supervision of a person who holds a license as a licensed
Residential Master Electrician or licensed Residential Journeyman Electrician provided the wiring is associated with dwellings, dwelling units
and detached accessory buildings and structures serving the dwellings or the dwelling units, such as garages, carports, gazebos and swimming
pools. Registered Electricians may perform electrical wiring under the direct supervision of a person who holds a license as a licensed
Industrial Journeyman Electrician provided the wiring is within the facilities or properties of the business establishment where the Industrial
Journeyman Electrician is employed.
AN APPLICATION IS NOT COMPLETE UNTIL ALL OF THE FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
1. Application and Fee: The fee consists of a $15.00 application fee and a $20.00 credential fee, based on a 1-year term from the date of
issuance.
#3108 (Rev. 8/18)
Class Code 7631 Page i
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Mail To: P.O. Box 78780 Office Location: 4822 Madison Yards Way
Milwaukee, WI 53293-0780 Madison, WI 53705
FAX #: (608) 267-0592 E-Mail: DSPSCredTrades@wi.gov
Phone #: (608) 266-2112 Website: http://dsps.wi.gov
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
APPLICATION FOR REGISTERED ELECTRICIAN REGISTRATION
The Department must deny your application if you are liable for delinquent state taxes, UI contributions, or child support (Wis. Stats. § 440.12 and 440.13).
PLEASE TYPE OR
PRINT IN INK
Your name, address, telephone and electronic address are available to the public. Check box to withhold address, telephone
number, and email address from lists of 10 or more credential holders (Wis. Stat. § 440.14).
Last Name
First Name
MI
Date of Birth
/ /
Address (street, city, state, zip)
Daytime Telephone Number
- -
Your Social Security Number must be submitted with your application on this form. If you do not have a
Social Security Number, you must complete Form #1051. The Department may not disclose the Social
Security Number collected except as authorized by law.
Have you ever held a Trades credential in WI? Yes No If yes, list your credential number:
Email Address
ARE YOU A VETERAN? If yes, please view the Department website at http://dsps.wi.gov for eligibility requirements.
If you qualify, are you requesting a waiver of your initial credentialing fee? Yes No
If Yes, provide a copy of your Department of Veterans Affairs voucher code and list your DVA Voucher Code Number:
You may contact the DVA at 1-800-WisVets or www.WISVETS.com for assistance in obtaining your DVA Voucher Code and/or documents
related to your training.
#3108 (Rev. 8/18)
Class Code 7631 Page 1 of 2
Committed to Equal Opportunity in Employment and Licensing
APPLICATION FEES:
Please check applicable box.
Make check
payable to DSPS and attach to this application.
I am seeking a Vet
eran Fee Waiver
(
for Initial Credential Fee
only, see further information
below
)
Initial Credential Fee
$15.00 Application Fee
$20
.00
Credential Fee
$35
Total Fee Attached
.00
Reinstatement
Fee
(
credential
expired more th
an 1 year)
$1
5
.00
Application
Fee
$20
.00
Credential
Fee
$
25
.00
Late Renewal
Fee
$60
.00
Total Fee Attached
APPLICATION IS NOT COMPLETE
UNTIL
ALL OF THE
FOLLOWING DOCUMENTS HAVE BEEN RECEIVED:
Fee and
Application
(
including signature on Pa
ge
2
)
Is name on all credentials the same? If not,
list former/maiden
name(s)
:
Wisconsin Department of Safety and Professional Services
CONTINUING EDUCATION AND RENEWAL REQUIREMENTS: Please view the Department website at http://dsps.wi.gov under
“Professions” and select “Electrician”.
CERTIFICATION OF LEGAL STATUS:
I declare under penalty of law that I am (check one):
A citizen or national of the United States, or
A qualified alien or nonimmigrant lawfully present in the United States who is eligible to receive this professional license or credential as
defined in the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, as codified in 8 U.S.C. §1601 et. Seq. (PRWORA).
For questions concerning PRWORA status, please contact the U.S. Citizenship and Immigration Services in the Department of Homeland
Security at 1-800-375-5283 or online at http://www.uscis.gov.
Should my legal status change during the application process or after a credential is granted, I understand that I must report this change to the
Wisconsin Department of Safety and Professional Services immediately.
CONTINUING DUTY OF DISCLOSURE
I understand that I have a continuing duty of disclosure during the application process. If information I have provided in this application becomes
invalid, incorrect or outdated, I understand that I am obliged to provide any necessary information to ensure the information on my application
remains current, valid, and truthful. I understand that Credentialing authorities may view acts of omission as dishonesty and that my duty of
disclosure during the application process exists until licensure is granted or denied.
AFFIDAVIT OF APPLICANT
I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every respect. I understand
that failure to provide requested information, making any materially false statement and/or giving any materially false information in connection with
my application for a credential or for renewal or reinstatement of a credential may result in credential application processing delays; denial,
revocation, suspension or limitation of my credential; or any combination thereof; or such other penalties as may be provided by law. I further
understand that if I am issued a credential, or renewal, or reinstatement thereof, failure to comply with the statutes and/or administrative code
provisions of the licensing authority will be cause of disciplinary action.
By signing below, I am signifying that I have read the above statements (Certification of Legal Status, Continuing Duty of Disclosure, and Affidavit
of Applicant) and understand the obligation I have as an applicant or credential-holder should information I’ve provided to the Department of Safety
and Professional Services change.
Signature: Date: / /
#3108 (Rev. 8/18)
Class Code 7631 Page 2 of 2
Committed to Equal Opportunity in Employment and Licensing
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Completed 9 April 2022

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