Psi Electrical Experience Verification Form Page 3
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1
2
3SIGNATURE OF PERSON CERTIFYING THE WORK EXPERIENCE: _______________________________________________
Candidate Name: ______________________________________________________ Date: ______________________
All experience must have been gained while employed by a contractor licensed in the trade being applied for, or considered legal
work in the state in which the work was performed. There are some limited exceptions to this work experience requirement. For
example certain military, volunteer, and homeowner experience may be used in some circumstances.
(CIRCLE ONE)
PART TIME or FULL TIME
1.
THIS WORK WAS PERFORMED FROM _______ / ________ TO _______ / _______
Hours per week __________
MO
YR
MO
YR
WHILE APPLICANT WAS EMPLOYED BY ______________________________________________CO. LICENSE #_________________
ATTACH A COPY OF THE LICENSE
*IF YOUR WORK EXPERIENCE IS WITH A COMPANY FROM A STATE THAT DOES NOT REQUIRE A LICENSE, YOU MUST SUBMIT
PR0OF/VERIFICATION THAT THE COMPANY IS AN ACTIVE/VALID COMPANY. (Tax certificate, business license listing the company
name, corporation papers, etc.)
2.
ADDITIONAL WORK EXPERIENCE INFORMATION ATTACHED
YES
NO (attachment must be signed)
3.
APPLICANT’S POSITION WHILE PERFORMING WORK: (CHECK ONE)
JOURNEYMAN FOREMAN SUPERVISOR CONTRACTOR OTHER_______________________________________
4.
I HELD THE FOLLOWING POSITION WHILE APPLICANT WAS PERFORMING THE WORK. (CHECK ONE)
EMPLOYER CONTRACTOR SUPERVISOR FOREMAN OTHER______________________________________________
*Contractors must attach a copy of their current state license, you must submit proof/verification of your position with the
company.
Do not leave any blanks!
Applications/work verifications that are incomplete or that do not have requested attachments will be rejected.
PERSON CERTIFYING (Print)
_______________________(
), I ___________________________(
In making this certification for
candidate name
person
, have not relied on statements made to me by applicant or third parties, and swear under penalty of perjury that the
certifying)
information provided in this certification is true and correct to the best of my personal knowledge. I understand that my license
may be subject to discipline if the information given and attested to by me herein is determined to be intentionally misleading or
fraudulent.
_________________________________________________ LICENSE # ________________ STATE _____________
Signature of Person Certifying
(Attach a copy of the license)
__________________________________________________________________________________________________________
Address
City
State
Zip
Phone # ___________________________ Fax # __________________________ Email _____________________________
NOTARY
Subscribed and sworn before me this _________________ day of ______________________20______
SEAL
____________________________________________________________________________________________________________
Notary Public
My commission expires___________________________________________ 20_______
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Updated 6/20/2014
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