Form Dlse-Ecf3 - Application For Electrician Exam Retest
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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
Application for Electrician Exam Retest
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: ___________________________________________________
Retest Exam Language Selection (check one):
English
Spanish
RETEST of Exam(s) Taken but Not Passed
OR
RETEST of Certification RENEWAL Exam
G
R
F
V
L
Check Exam(s) not passed:
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
R
F
V
L
= General
= Residential
= Fire/Life Safety
= Voice Data Video
= Nonresidential Lighting
RETEST of Exam(s) Scheduled but not Taken
G
R
F
V
L
Check Exam(s) not taken:
Date(s) scheduled:
ECP Tracking Nbr(s) (if known):
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.
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:
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-ECF3 (3-2015)
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