Form Cc0100 - Work Experience Verification Form For Power Limited Technician

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Minnesota Department of Labor and Industry
Construction Codes and Licensing Division
PO Box 64227
St. Paul, MN 55164-0227
Phone: 651.284.5031
Email:
dli.exam@state.mn.us
Web site:
Power Limited Technician
P
clearly
I
RINT
IN
NK OR TYPE
M
Work Experience Verification Form
AKE A COPY OF THIS FORM FOR YOUR RECORDS
Applicant’s Legal Name:
License / Registration Number: (if applicable)
SSN: (Last 4 digits Only)
To apply for licensure and examination, the applicant must provide verification of their employment and qualifying work. Verification information required
includes: name, address, and phone number of the employer, applicant's dates of employment with the employer, class of work performed; and hours
worked. The information provided on this form is public data and shall be used to qualify the individual identified above for licensure and examination.
Individuals with multiple employers during the reporting period must make copies of the form and have each employer complete a separate
verification.
Employer Name
License / Registration Number
Employer Address
Telephone
City
State
Zip
Email Address
Name of Responsible Person (Power Limited Tech)
License Number
Title
Qualifying work experience is measured on a monthly basis. In order to accurately verify qualifying experience, the actual h ours worked
in each Class of Work must be reported. Credit of not more than 160 hours per month or 2000 hours per year is allowed as qualifying
experience. Hours reported on this form must be supported by records maintained by the employer and demonstrate experience
qualifying with M.S. §326B.33 and M.S. Rule 3800.3520. Knowingly providing inaccurate or fraudulent information may s ubject the
violator to disciplinary action and a monetary penalty of up to $10,000 per violation. To obtain additional information regar ding work
experience please visit our website at
Are the hours reported on this form
Complete a SEPARATE work experience form for each year of employment.
taken from payroll records?
Date of Employment:
YES
OTHER (specify)
Start Date:
End Date:
CLASS OF WORK
For Office
Hours Worked
Use Only
32
W
IRING FOR AND INSTALLING TECHNOLOGY CIRCUIT OR SYSTEM WIRING APPARATUS AND
EQUIPMENT
33
M
,
AINTAINING AND REPAIRING TECHNOLOGY CIRCUIT OR SYSTEM WIRING
APPARATUS AND
EQUIPMENT
36
W
IRING AND MAINTAINING PROCESS CONTROL CIRCUITS OR SYSTEMS
38
P
LANNING FOR THE INSTALLATION OF WIRING APPARATUS AND EQUIPMENT FOR TECHNOLOGY
CIRCUITS OR SYSTEMS
39
L
,
AYING OUT FOR THE INSTALLATION OF WIRING
APPARATUS AND EQUIPMENT FOR TECHNOLOGY
CIRCUITS OR SYSTEMS
40
S
,
UPERVISING THE INSTALLATION OF WIRING
APPARATUS AND EQUIPMENT FOR TECHNOLOGY
CIRCUITS OR SYSTEMS
TOTAL OF ALL QUALIFYING HOURS WORKED (M
2,000
)
AX
HOURS PER YEAR
– 36
T
= 6,000
OTAL OF ALL QUALIFYING HOURS WORKED
MONTHS EXPERIENCE REQUIRED TO TAKE EXAM
HOURS
Form must be signed by the designated Responsible Person and Applicant. I certify that I personally know or that the employer’s
employment records verify that this individual, during the referenced employment period, engaged in the identified classes of work for
the number of hours shown. The applicant's signature below acknowledges agreement with the information provided on this form.
RESPONSIBLE PERSON’S SIGNATURE
DATE SIGNED
APPLICANT'S SIGNATURE
DATE SIGNED
CC0100 Power Limited Tech Work Experience (10/2016)

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