Psi Electrical Experience Verification Form Page 2
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3ELECTRICAL EXPERIENCE VERIFICATION
Candidate Name: ______________________________________________________ Date: ______________________
Address: _____________________________________________City_________________State________Zip_________
SS#: ____________________________ CLASSIFICATION(s) APPLYING FOR: ___________________________________
*A COMPLETED QUALIFYING PARTY or JOURNEYMAN APPLICATION MUST BE SUBMITTED WITH THIS AFFIDAVIT.
USE ONLY INK AND DO NOT MAKE CORRECTIONS USING CORRECTIVE FLUID OR ANY OTHER MEANS.
INCOMPLETE, ILLEGIBLE OR CORRECTED FORMS WILL BE RETURNED AND PROCESSING WILL BE DELAYED.
RESIDENTIAL, COMMERCIAL AND INDUSTRIAL - REQUIRED EXPERIENCE
*CIRCLE THE CLASSIFICATION THE APPLICANT IS APPLYING FOR AND CHECK THE BOXES THAT APPLY TO THE CANDIDATE’S
WORK EXPERIENCE AND LIST THE HOURS OF EXPERIENCE. YOU MAY ATTACH ANY ADDITIONAL INFORMATION IN REFERENCE
TO THE APPLICANT’S WORK EXPERIENCE. ALL ATTACHMENTS MUST BE SIGNED.
EE98/EE98J – RESIDENTAL AND COMMERCIAL ELECTRICAL
Underground installation (e.g. conduit installation, underground conductor or cable installation)
Rough in installation (e.g. conduit installation, pull conductors, install cable, terminate conductors, install
boxes, install electrical panels)
Trim out (e.g. install receptacles or devices, install appliances, install breakers, install luminaires)
ER1/ER1J – RESIDENTIAL ELECTRICAL
Commercial Hours ____________
Underground installation (e.g. conduit installation, underground conductor or
cable installation)
Residential Hours _____________
Rough in installation (e.g. conduit installation, pull conductors, install cable,
terminate conductors, install boxes, install electrical panels)
TOTAL HOURS _____________
Trim out (e.g. install receptacles or devices, install appliances, install
breakers, install luminaires)
SPECIALTIES - REQUIRED EXPERIENCE
*CIRCLE THE CLASSIFICATION THE APPLICANT IS APPLYING FOR AND CHECK THE BOXES THAT APPLY TO THE CANDIDATE’S
WORK EXPERIENCE AND LIST THE HOURS OF EXPERIENCE. YOU MAY ATTACH ANY ADDIITIONAL INFORMATION IN REFERENCE
TO THE APPLICANT’S WORK EXPERIENCE. ALL ATTACHMENTS MUST BE SIGNED.
E1J/ES -1 SIGNS
Rough in (e.g. install concrete base, install sign enclosure)
)
Trim out (e.g. install lamps in signs, install sign, install transformers
TOTAL HOURS _______________
EL1J/EL1 ELECTRICAL DISTRIBUTION/TRANSMISSION
Underground installations (ductwork, underground conductor or cable
installations, terminations)
Overhead distribution (pole, conductor installations, transformer
installations, terminations)
Overhead transmission (poles/towers, tower foundations, conductor
installations, terminations)
Substations (transformers, switches, terminal facilities)
TOTAL HOURS _______________
ES2J/ES-2 CATHODIC LIGHTNING PROTECTION
Underground (e.g. install cable and conduit)
Trim out (e.g. install rectifier, other electrical equipment associated
with cathodic or lightning systems)
TOTAL HOURS _______________
ES3J/ES-3 LOW VOLTAGE
Rough in (e.g. install boxes, cable, equipment)
Trim out (e.g. install low voltage equipment and devices, test equipment)
TOTAL HOURS _______________
ES7J/ES-7 TELEPHONE
Underground (e.g. install cable, junction boxes)
Overhead (e.g. install cables, conductors, support structures)
Trim out (e.g. terminate conductors, install telephone equipment
and devices, and test)
TOTAL HOURS _________________
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Updated 6/20/2014
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