Form Cc0100 - Work Experience Verification Form For Power Limited Technician Page 2
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1
2INSTRUCTIONS
Employer must complete the Work Experience Verification Form.
READ CAREFULLY BEFORE COMPLETING THIS FORM
REGISTERED UNLICENSED INDIVIDUAL WORK EXPERIENCE
Registered unlicensed individuals, as part of renewing their registration, must provide verification of their employment by a
licensed contractor or registered employer during the registration period. This form reports the verified hours and is adapted for
use by unlicensed individuals registered to perform electrical work. The reason for verifying work hours each year along with
renewing a registration is so the registered individual does not have to verify these hours when applying for a license
examination. Verifying hours annually when renewing a registration enables the department to gradually qualify an individual for
examination, which makes for quicker approvals.
•
Address information on the form is the unlicensed individual’s mailing address. Updates to the individual’s personal or
mailing address may be noted on the registration renewal form. Address changes may also be made by emailing
dli.license@state.mn.us
•
Provide exact dates of employment during the 12-month registration period (expiration date of unlicensed registration card).
Include the month, day, and year.
•
Indicate whether the hours reported on the form are taken from payroll records; and if not, specify the other forms of
documentation used to verify the individual’s work experience.
•
For each class of work identified, enter the actual hours the individual performed that class of work during the
registration period. (Note: Blanks will be assigned 0 hours.)
•
Enter the total number of electrical work hours verified, which may not exceed 2,000 hours.
EMPLOYER INFORMATION (MANDATORY INFORMATION)
•
Enter the employer’s business name, address, license or registration number, contact’s phone number, and email
address. (NOTE: License number is mandatory, if business holds contractor license number.)
•
Enter the employer’s designated responsible individual’s name and license number. The individual’s license number must
match what the department has on record as the designated responsible individual and license number.
OUT OF STATE WORK EXPERIENCE
•
Provide exact dates of employment during the 12-month Include the month, day, and year.
•
Indicate whether the hours reported on the form are taken from payroll records; and if not, specify the other forms of
documentation used to verify the individual’s work experience, must be verified by an individual/business that is properly licensed to
perform that work in that state..
•
For each class of work identified, enter the actual hours the individual performed that class of work during the
registration period. (Note: Blanks will be assigned 0 hours, total number of electrical work hours verified, may not exceed 2,000
hours.)
If self-employed provide two written statements from either authorized electrical or building inspector or other electrical
contractors conducting business in the same vicinity per Minn. Rule 3800.3520.
Certification Signature and Date
•
The employer’s designated responsible individual must certify, with a signature, that the registered unlicensed individual
performed the identified classes of work for the number of hours entered on the form during the 12-month registration period.
•
The registered unlicensed individual’s signature on the form acknowledges agreement with the information verified by the
employer.
QUALIFYING FOR A LICENSE EXAMINATION
Work verification is for the following license classifications, which require a minimum number of months/hours qualifying work
experience to become licensed. Detailed information on qualifying for a license exam is available at
License Class
Law (Rule)
Requirement
Minimum Requirements
2,000 hours – wiring for and
Power Limited Technician
326B.33 (3800.3520)
36 Months 6,000
installing technology circuit or
system wiring, apparatus, and
equipment:
*A maximum of one year (2,000 hours) of experience credit will be allowed for the successful completion of a two-
year post- high school technical course approved by the department.
CC0100 Electrical Work Experience (10/2016)
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