Fillable to Practice as a Qualied Journeyman Electrician Application (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Office of the Attorney General
Division of Consumer Affairs
Board of Examiners of Electrical Contractors
124 Halsey Street, 6th Floor, P.O. Box 45006
Newark, New Jersey 07101
(973) 504-6410
Application for a Certicate of Registration
to Practice as a Qualied Journeyman Electrician
Date: _____________________________
N.J.A.C. 13:31-5.1 Registration as qualied journeyman electrician
The term “qualied journeyman electrician” as used in N.J.S.A. 45:5A-18(k) or N.J.A.C. 13:31-3.4 shall mean and include any person
who is either: (1) The holder of a current valid license to practice electrical contracting issued by the Board; or (2) A person who has
acquired 8,000 hours of practical experience working with tools in the installation, alteration, or repair of wiring for electric light, heat
or power and who has had a minimum of 576 classroom hours of related instruction. The requirement of practical experience shall not
include time spent in supervising, engineering, estimating, and other managerial tasks. At least 4,000 hours of the practical experience
shall have been obtained within ve (5) years of the date of application; or (3) A person who can demonstrate to the satisfaction of the
Board that he or she has gathered the required experience through alternative means.
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application (including your address of record) may be subject to public disclosure as required by
the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _____________________
Month Day Year
Place of birth: ____________________
City State
Mr.
1. Name Mrs. __________________________________________________________ ( ____________________ )
Ms.
Last name First name Middle initial Maiden name
2. Address
Home:______________________________________________________________________________________
Street or P.O. Box City State ZIP code County
__________________________________ ________________________________
Telephone number (include area code) E-mail address
Business: ___________________________________________________________________________________
Name of company Telephone number (include area code)
____________________________________________________________________________________
Street City State ZIP code County
Mailing: ____________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Attach a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photo is required with each
application.
Do not use staples to attach the
photograph.
Date of photograph:
________________________
Month Day Year
3. SocialSecurityNumber
IfyouwereissuedaSocialSecurityNumberoranIndividualTaxpayerIdenticationNumber,youmustprovideittotheBoardor
Committee.Failuretodosomayresultindenialoflicensure/certication/reinstatement/reactivation.
*SocialSecurityNumber: __________-__________-__________
*IndividualTaxpayerIdenticationNumber: __________-__________-__________
*PursuanttoN.J.S.A.54:50-24etseq.oftheNewJerseytaxationlaw,N.J.S.A.2A:17-56.44eoftheNewJerseyChildEnforcement
Law,Section1128E(b)(2)AoftheSocialSecurityActand45C.F.R.60.7,60.8and60.9,theBoardorCommitteeisrequiredto
obtainthisinformation.Pursuanttotheseauthorities,theBoardorCommitteeisalsoobligatedtoprovidethisinformationto:
(For healthcare-related boards, the following a, b and c entries apply. For boards not related to healthcare, only the a and b
entries apply.)
 a. theDirectorofTaxationtoassistintheadministrationandenforcementofanytaxlaw,includingforthepurposeof
reviewingcompliancewithStatetaxlawandupdatingandcorrectingtaxrecords;
b. theProbationDivisionoranyotheragencyresponsibleforchild-supportenforcement,uponrequest;and
c. theNationalPractitionerDataBankandtheH.I.P.DataBank,whenreportingadverseactionsrelatingtohealthcare
professionals.
4. Citizenship/ImmigrationStatus
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied
aliens. To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration
status. If you are anAmerican citizen, please enclose a copy of your birth certificate or U.S. passport. If you are not
aU.S.citizen,attachacopyofyouralienregistrationcard(frontandback)orotherdocumentationissuedbytheofceofU.S.
CitizenshipandImmigrationServices(USCIS).
 U.S.citizen
 AlienlawfullyadmittedforpermanentresidenceinU.S.
 Otherimmigrationstatus
Questionsaboutyourimmigrationstatusandwhetherornotitisaqualifyingstatusunderfederallawshouldbedirectedtothe
USCISat:1-800-375-5283.
5. StudentLoan
Areyouindefaultinregardtoanystudentloanobligation(s)? Yes No
If“Yes,”youmustobtaindocumentaryevidencethatyouhavereachedanarrangementwiththebankorwiththeentitythatissued
yourstudentloan,fortheeventualrepaymentoftheloan.Youwillnotbeabletoobtainalicenseorcerticateunlessyouprovidethe
requireddocumentsconcerningtheplanforrepaymentofyourstudentloan.
6. ChildSupport(You must answer a, b, c and d.)
Pleasecertify,underpenaltyofperjury,thefollowing:
a. Doyoucurrentlyhaveachild-supportobligation? Yes No
(1)If“Yes,”areyouinarrearsinpaymentofsaidobligation? Yes No
(2)If“Yes,”doesthearrearagematchorexceedthetotalamountpayableforthepastsixmonths? Yes No
b. Haveyoufailedtoprovideanycourt-orderedhealthinsurancecoverageduringthepastsixmonths? Yes No
c. Haveyoufailedtorespondtoasubpoenarelatingtoeitherapaternityorchild-supportproceeding? Yes No
d. Areyouthesubjectofachild-support-relatedarrestwarrant? Yes No
InaccordancewithN.J.S.A.2A:17-56.44d,ananswerof“Yes”toanyofthequestionsathroughdmayresultindenialoflicensureor
certication.Furthermore,anyfalsecerticationoftheabovemaysubjectyoutoapenalty,including,butnotlimitedto,immediate
revocationorsuspensionoflicensureorcertication.
 ___________________________________ ___________________________________ ________________________

Applicant’sname(pleaseprint) Applicant’ssignature Date
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signature
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7. Have you ever changed your name? Yes No
If “Yes,” please submit with this application a copy of the marriage certicate, divorce decree or court order.
8. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? (Parking or speeding violations need not be disclosed, but motor vehicle
violations such as driving while impaired or intoxicated must be.) Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete explanation.
(Use additional sheets of paper if necessary.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
9. Have you ever been convicted of any crime or offense under any circumstances? This includes, but is not limited to, a plea of guilty,
non vult, nolo contendere, no contest, or a nding of guilt by a judge or jury. Yes No
If “Yes,” provide a copy of the judgment of conviction and the release from parole or probation. Please provide a complete
explanation. (Attach additional sheets of paper to this application.)
10. Do you currently hold, or have you ever held, a professional or occupational license or certicate of any kind in New Jersey, any other state, the
District of Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license or certicate held, provide the date(s) held and the number(s). If the license or certicate was issued under
a different name, please provide that name. ____________________________________________________________________
Last name First name Middle initial
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
_____________________ _______________________ ____________________________ ____________________
Type of license or certicate Number State or jurisdiction that issued the license or certicate Date issued/expired
11. Have you ever been disciplined or denied a professional or occupational license or certicate of any kind in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
12. Have you ever had a professional or occupational license or certicate of any type suspended, revoked or surrendered in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
13. Has any action (including the assessment of nes or other penalties) ever been taken against your professional or occupational
practice by any agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
14. Have you ever been named as a defendant in any litigation related to the practice of a Qualied Journeyman Electrician or other
professional or occupational practice in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
15. Are you aware of any investigation pending against a professional or occupational license or certicate issued to you by a
professional or occupational board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
16. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
17. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional or
occupational group related to the practice of a Qualied Journeyman Electrician or other professional or occupational practice in
New Jersey, any other state, the District of Columbia or in any other jurisdiction? Yes No
If the answer to any of the above questions, numbers 11 through 17, is “Yes,” provide a complete explanation of the circumstances
leading to the action, and any supporting documentation, on separate sheets of paper.
18. Please provide proof of your practical experience working with tools (submit work-experience certications).
a. Total work experience __________ (years) and average number of hours worked per week _________.
b. Technical trade school or approved apprenticeship course - total hours __________.
You must submit a copy of the certicate of course completion and indicate the total number of years attended.
c. I hold a current active New Jersey Electrical Contractor’s License, number _______________________.
19. Detailed Statement of Experience:
Give a detailed account of your practical experience in the eld working with tools in the installation,
alteration, or repair of wiring for electric light, heat or power, giving dates, employer(s) and duties
for a minimum of the past ve (5) years; 8,000 hours of practical experience is required, at least 4,000 hours
of which shall have been obtained within ve (5) years of the date of the application. Attach completed work-
experience certication(s) for each employer. (Use additional sheets of paper if necessary.)
20. Application Fee
Upon approval of your application, you will receive a letter of notication at which time your registration fee will be due.
Dates
Month/Year
to
Month/Year
Employer Duties
AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: __________________________________________________
County of: ________________________________________________
I, ________________________________________________ , in making this application to the Board of Examiners of Electrical
Contractors for certication, registration or licensure under the provisions of Title 45 of the General Statutes of New Jersey and the
Rules of the Board of Examiners of Electrical Contractors, swear (or afrm) that I am the applicant and that all information provided in
connection with this application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure
to make full disclosures may be deemed sufcient to deny certication, registration or licensure or to withhold renewal of or suspend or
revoke a certicate, registration or license issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:5A-1 et seq., together with the Rules and Regulations of the Board of Examiners
of Electrical Contractors, N.J.A.C. 13:31-1.1 et seq., and fully understand that in receiving certication, registration or licensure from
the Board, I bind myself to be governed by the aforementioned Statute and the Rules and Regulations of the Board of Examiners of
Electrical Contractors.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for the purpose
of verifying my qualications for certication, registration or licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records requested by the
Board.
_____________________________________________
Signature of applicant
Sworn and subscribed to before me this
day of _________________________ , _____________
______________________________________________
Name of Notary Public (please print)
______________________________________________
Signature of Notary Public
} ss.
Afx Seal Here
Month Year
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signature
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signature
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New Jersey Office of the Attorney General
Division of Consumer Affairs
Board of Examiners of Electrical Contractors
124 Halsey Street, 6th Floor, P.O. Box 45006
Newark, New Jersey 07101
(973) 504-6410
Work-Experience Certication for Qualied Journeyman Electrician
(To be completed by the individual named as a reference.) (Please print.)
__________________________________________________ _____________________________________________
Name of applicant Name of reference and company name
__________________________________________________ _____________________________________________
Applicant’s address Reference’s address
__________________________________________________ _____________________________________________
City State ZIP code
City State ZIP code
__________________________________________________ _____________________________________________
Telephone number (include area code) Internet address
1. Applicant’s practical hands-on experience working with tools in the installation, alteration, or repair of wiring for electric
light, heat or power.
A. Exact dates: From: ______ / ________ / ________ to _________ / _________ / _________
B. Average number of hours per week: ______________
C. Explain electrical experience.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Are you an electrical contractor? Yes No
If “Yes,” in what state? ___________________________________ License number: ____________________________
If you are a New Jersey Electrical Contractor, impress your Business Permit Seal.
Afx
Seal
Here
3. I hereby certify that I am the ________________________________________ of _______________________________
Reference/Title Company
and that I have personal knowledge of the qualications of the applicant and that he/she worked for me in the installation,
alteration, or repair of wiring for electric light, heat or power with tools in the eld during the time stated.
______________________________________________ _____________________________________________
Signature of reference Date
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Completed 14 August 2020

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