Form Dlse-Ecf2 - Request For Replacement Certification Card Or Report Of Address Change
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State of California
DL State _____ Driver’s License # __________________
DIR – Labor Standards and Enforcement
Payment Amount $ __________
Date of Birth (MM/DD/YYYY) _____/______/_______
Electrician Certification Program
Phone (510) 286-3900
Request for Replacement Certification Card
OR
Report of Address Change
Please PRINT or TYPE all information in INK
Last Name:
First Name:
MI:
Name must match U. S. Drivers License or State ID:
Mailing Address:
City:
____________________________State:
Zip: _______________-_______________________
Day Phone: (____)_____-_______
Email: ___________________________________________________
Card #: E-
_
E-
_
E-
_
(print affected card numbers)
Check one box Only:
1
Address / phone change only (No name change) – Information is above – No new card – No fee
2
Mistake / Misprint on card – Replace with changes indicated below – No fee if approved
3
Lost / Stolen card – Replace with duplicate – Fee is $30.00 for each card, payable as below
4
Name Change – Replace with new name below – Fee is $30.00 for each card, payable as below
Name on card is wrong – Correct / New name is:
Certificate start or end date(s) wrong – Should be:
Also check this box if Address has changed (for boxes 2, 3, 4)
Note - You also need to attach to this request:
If box 1 is checked, just sign, date, and mail this form.
If box 2 or 4 is checked, attach the current card(s) with the incorrect information.
If box 3 or 4 is checked, attach payment totaling $30 for each card (non-refundable).
I certify under penalty of perjury that all statements and attachments are true and correct.
Signature:
Date:
Submit form with original signature and keep a copy for your records.
Incomplete or inaccurately paid requests 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:
DIR-Division of Labor Standards Enforcement
Attn: Electrician Certification Unit
PO Box 511286
Los Angeles, CA 90051-7841
(For Office Use) Approved by:
Date:
Form DLSE-ECF2 (3-2015)
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Parent category: Legal