For Office Use Only
Type of Contractor’s Licence Issued
Electrical Contractor's
CB
SA
CA
CR
RW
Application/
Annual Renewal
Approved By
Technical Inspector II (E) Signature
Type of Application
1
Renewal
New Registration
New applications for Specialty Licenses (SA) in accordance with Part 1 of Public Safety Act must be accompanied by letter of explanation for
the Chief Electrical Inspector’s approval
Type of Applicant (check one only)
2
Owner
Partnership
Corporation
Representative
Applicant Information (Please type or print in ink)
3
Name of Applicant
If for Renewal, state Contractor’s Registration Number
Address
Postal Code
Cellular Telephone
Business Telephone
Fax
Contact information will be posted to Government’s website and will be publicly accessible.
Certificate of Qualification for Contractor’s Representative
(If more than one, please attach additional sheets if extra space is required)
4
Indicate Type of Licence
Inter-Provincial Journeyperson
Inter-Provincial Journeyperson
Residential
CB Licence
Electrical Construction
Industrial Electrician
Electrician
Issued By (Province or Territory)
Licence Number
Original Date of Issue
Expiry Date (if applicable)
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Sole Owner (Complete if applicable. If Partnership/Corporation skip this question and proceed to section 6)
5
Business Name
Partnership/Corporation Information (Complete if applicable. If Sole Owner proceed to section 8)
6
Name of Partnership or Corporation
Mailing address of Partnership or Corporation
Registered address of Partnership or Corporation
Business Telephone
Fax
Cellular Telephone
Name of Manager of the Partnership's/Corporation's
Electrical Contracting Department/Division (please print)
Manager's Address (if different from above)
Manager’s Signature
Business Telephone
Attach list of Partners and/or Directors of Corporation on a separate sheet, if applicable.
Continued on Reverse