Electrical Application/renewal Form Page 2

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Certification (Please complete if Partnership / Corporation. (If sole owner skip this section and proceed Section 8)
7
I ____________________________________________________ certify that I am properly authorized to make this application on behalf of
Name of Manager / Signing Officer
the company or corporation indicated in Section 6 of this form and that _______________________________________________________
Contractor’s Representative
has been designated Contractor’s Representative for this company.
This company will ensure that the requirements and associated adopted electrical codes and standards are fulfilled for all work
undertaken and that electrical work will be performed by personnel who have been trained and certified by a recognized authority.
Signature of Manager / Signing Officer
Date
Y
Y
Y
Y
M
M
D
D
Affirmation
8
Affirmation (Not required for renewal if there has been no material change from previous application.)
I/we affirm that the information given in this application is true and complete to the best of my/our knowledge and belief.
I/we declare that I/we have read and understand the obligations under the Public Safety Act and The Electrical Regulations and will
comply with the terms and conditions of this Registration Certificate. I/we hereby undertake to notify the Department of Government
Services in writing of any material change affecting this application. I/we understand that I/we will be subject to periodic inspections/
audits for the purpose of ensuring compliance with the Public Safety Act and The Electrical Regulations and the Canadian Electrical Code.
I/we make this declaration knowing that it has the same force and effect as if made under the provisions of The Canada Evidence Act.
Declared before me
Signature of Applicant
at ________________________________________________
in the _________________ of _________________________
1
January
this _____ day of __________________________, 20_____.
Commissioner of Oaths / Justice of the Peace /
Notary Public - with raised seal (if completed outside
Newfoundland and Labrador)
Signature of Manager / Signing Officer
Method of Payment
9
Money Order
Invoice
Purchase Order:
P . O. #
Cash
Debit
Cheque
Credit Card Number
Credit Card
Credit Card Expiration Date
Signature on Credit Card
Y
Y
Y
Y
M
M
Visa
Mastercard
All cheques/money orders are to be made payable to the Newfoundland Exchequer Account.
"WHERE THE FEE PAID IS INSUFFICIENT, THE BALANCE SHALL BE PAID UPON REQUEST.”
Routing Information
10
Forward completed form to the nearest regional office of the Government Service Centre listed below:
MOUNT PEARL
HARBOUR GRACE
CLARENVILLE
GANDER
Motor Registration Building
7-9 Roddick Crescent
8 Myer’s Avenue
Fraser Mall
Telephone: (709) 729-2498
Telephone: (709) 945-3106
Telephone: (709) 466-4060
Telephone: (709) 256-1420
Facsimile: (709) 729-7400
Facsimile: (709) 945-3114
Facsimile: (709) 466-4070
Facsimile: (709) 256-1438
CORNER BROOK
GRAND FALLS-WINDSOR
HAPPY VALLEY-GOOSE BAY
Sir Richard Squires Building
3 Cromer Avenue
2 Tenth Street
Telephone: (709) 637-2369
Telephone: (709) 292-4206
Telephone: (709) 896-5428
Facsimile: (709) 637-2681
Facsimile: (709) 292-4149
Facsimile: (709) 896-4340
PRIVACY NOTICE
The Government Service Centre collects personal information relating to electrical contractors under the authority of the Public Safety Act. This information may be shared with
Motor Registration Division for the purposes of receipting at Government Service Centres and the Department of Education, Industrial Training Division, for the administration of the
Plan of Training under the Apprenticeship Training and Certification Act. Personal information collected by the Government of Newfoundland and Labrador is protected under the
Access to Information and Protection of Privacy (ATIPP) Act. If you have any questions about the collection or use of this information, please contact a Government Service Centre
representative at your nearest Government Services office.

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