Fillable CERTIFICATION OF WORK EXPERIENCE General Information (California)

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CERTIFICATION OF WORK EXPERIENCE General Information (California)

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CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA
9821 Business Park Drive, Sacramento, CA 95827
Mailing Address: P.O. Box 26000, Sacramento, CA 95826
800.321.CSLB (2752) |
Governor Gavin Newsom
www.cslb.ca.gov | CheckTheLicenseFirst.com
13A-11 (rev. 06/17) Certification of Work Experience – General Information
CERTIFICATION OF WORK EXPERIENCE
General Information
This form must be filled in completely in order to document applicant’s work experience, or the application will be
returned for correction or completion. The qualifying individual on the application (as listed on Page 1 of the application)
and certifier (a qualified and responsible person who verifies the experience in the classification for which the applicant
is seeking licensure) must type or print neatly and legibly in black or dark blue ink – pencil is not acceptable.
FORMS CONTAINING STRIKEOUTS OR MODIFICATIONS MAY NOT BE ACCEPTED.
Corrections on the Certification of Work Experience forms must be initialed by the certifier.
Original signatures are required – faxed, photocopied, or stamped signatures are not acceptable.
All qualifying individuals and certifiers must be at least 18 years old.
All Certification of Work Experience forms must be submitted with the application.
The Certification of Work Experience form, when filed with an application, becomes the property of CSLB and is kept as a matter of
record. Keep a copy of the completed and signed form for your records – you may be asked to provide further documentation
or testimony to verify your experience. A random three percent (3%) of applications are subject to review, and experience must be
verifiable through payroll records and similar documents. CSLB staff may contact the certifier or other parties to verify experience.
If you have ever served as a qualifier on a license in the classification for which you are now applying, you may not need to
complete this form. However, if you are applying for a waiver of the examination pursuant to Business and Professions Code (BPC)
sections 7065.1(b) or 7065.1(c), you do need to complete this form. (Please refer to CSLB’s website for more information on exam
waivers.) NOTE: If you had a previous application that was denied on the basis of a lack of qualifying work experience,
you must complete this form, regardless of whether or not you passed the examination.
Anyone who knowingly procures or offers false or forged documents to be filed, registered, or recorded in any public
office in California is guilty of a felony. (Penal Code section 115)
PART 1 – QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION
The qualifying individual (qualifier) must complete Part 1 in its entirety before the certifier completes Part 2.
Lines 2 and 3 request the business name of company, license number of company, and company’s business street address of the
place where your experience was gained, which may or may not have been your employer.
PART 2 – WORK EXPERIENCE AND CERTIFICATION STATEMENT
The certifier must complete Part 2 in its entirety after the qualifying individual has completed Part 1.
The qualifying individual must document at least four (4) years of journeyman-level or higher experience in the
classification for which they are applying. The experience must have been obtained within the last 10 years.
The qualifying individual’s work experience must have been completed at the level of journeyman, foreman, supervising
employee, or contractor, as defined below (Title 16, California Code of Regulations [T16 CCR] section 825). Also defined below
are “owner-builder” and “self-employed individual.”
▫ A “journeyman” is an experienced worker who is fully qualified (as opposed to a trainee) and is able to perform the trade
without supervision, or a person who has completed an apprenticeship program. (T16 CCR section 825)
▫ A “foreman” or “supervising employee” is a person who has the knowledge and skills of a journeyman and directly
supervises construction projects.
▫ A “contractor” is an individual who is currently a licensed California contractor, a former licensed California contractor, or an
out-of-state licensed contractor. A contractor has the skills necessary to manage the daily activities of a construction business,
including field supervision.
▫ An “owner-builder” (a person who performs B-General Building classification work solely on their own property, pursuant to
BPC section 7044) or a “self-employed individual” must have the knowledge and skills of a journeyman as listed above and
the skills necessary to manage the daily activities of a construction business, including field observation. Owner-builders must
complete and submit an Owner-Builder B-General Building Construction Project Experience form for each owner-builder
project on their own property.
The Description of Classifications document may be used as a reference only and is available through a link on the Applicants
page of CSLB’s website.
The certifier (a qualified, responsible person who is able to verify the work experience of the qualifier) must complete and
date and sign under the certification statement on line 9 at the bottom of the form. The certifier can be an employer, fellow
employee, journeyman, union representative, contractor, business associate, or a client if the applicant is/was self-employed. This
form will help CSLB determine whether the qualifier has the experience necessary to become a qualified contractor.
The certifier must have direct knowledge of the qualifier’s experience during the time period listed. “Direct knowledge”
means personal knowledge of the experience that does not depend on outside information or hearsay. The certifier must be able to
certify that the qualifier demonstrated a level of knowledge and skills expected of a journeyman or higher in the classification for
which they are applying.
Any licensee whose signature appears on a falsified Certification of Work Experience form, or who otherwise certifies
false or misleading experience claims submitted by an applicant to obtain a contractor license, will be subject to
disciplinary action. (BPC section 7114.1)
CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA
9821 Business Park Drive, Sacramento, CA 95827
Governor Gavin Newsom
Mailing Address: P.O. Box 26000, Sacramento, CA 95826
800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com
13A-11 (rev. 06/17) Certification of Work Experience
Certification of Work Experience
Please read the General Information on the previous page before beginning this form.
The qualifying individual from Page 1 of the application must complete the information in Part 1 below; then, the certifier (person certifying the
experience) must complete Part 2. The experience must be verifiable through payroll records or similar documents. If additional space is needed to list
the trade duties, please attach a separate sheet that must also be signed under the same certification statement contained below in line 9.
Use a separate form for each employer or work setting. If you need additional forms, please make a copy of this blank form or visit CSLB’s website to
print the form.
Please type or print neatly and legibly in black or dark blue ink – pencil is not acceptable.
FORMS CONTAINING STRIKEOUTS OR MODIFICATIONS MAY NOT BE ACCEPTED. Corrections must be initialed by the certifier.
PART 1 – QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION
The qualifying individual must complete Part 1 in its entirety before the certifier completes Part 2.
1. QUALIFIER’S FULL LEGAL NAME Last First Middle
2. BUSINESS NAME OF COMPANY WHERE EXPERIENCE WAS GAINED – OR, IF YOU WERE SELF-EMPLOYED, LEAVE
THIS SPACE BLANK AND CHECK THIS BOX
(If you checked the box, skip line 3 and go to line 4.)
LICENSE NUMBER OF COMPANY
WHERE EXPERIENCE WAS GAINED
3. COMPANY’S BUSINESS STREET ADDRESS Number/Street Only – NO P.O. Boxes City State ZIP Code
4. WAS THE EXPERIENCE OBTAINED WORKING ON YOUR OWN PROPERTY AS AN OWNER-BUILDER (see previous page for definition)?
If you checked “Yes” above, use the Owner-Builder B-General Building Construction Project Experience form to provide information on completed projects.
Yes No
PART 2 – WORK EXPERIENCE AND CERTIFICATION STATEMENT
The certifier must complete Part 2 in its entirety after the qualifying individual (applicant) has completed Part 1.
5. APPLICANT’S
JOURNEYMAN-
LEVEL OR HIGHER
TIME-BASE
WORKED IN
SPECIFIC TRADE
DUTIES (check one):
FULL-TIME
PART-TIME
FOR A TOTAL OF
} FROM_________________ TO _________________ = ______________ YEAR(S) and ______________ MONTH(S)
Month/Day/Year Month/Day/Year (Do not claim credit for full-time work if applicant worked
only part-time or if trade duties in requested classification
were only one component of entire job. For example, if
applicant worked half-time in specific trade duties for
six (6) years, write “3 years” in the space above.)
(List ONLY journeyman-level or higher experience
that was obtained in the applicable classification.)
6. IN THE SPACE BELOW, LIST ALL SPECIFIC TRADE DUTIES APPLICANT PERFORMED OR SUPERVISED IN THE CLASSIFICATION FOR WHICH THEY ARE
APPLYING. PLEASE REFER TO THE DESCRIPTION OF CLASSIFICATIONS DOCUMENT FOR ASSISTANCE. (Do not list office work or individual project names.)
7. My business relationship to _________________________________________________________________________________________ is or was (check all that apply):
Name of Qualifying Individual (Applicant)
Employer Contractor (License Number ____________________________) Foreman or Supervisor
Journeyman Fellow Employee Union Representative Business Associate
8. CERTIFIER’S STREET ADDRESS Number/Street Only – NO P.O. Boxes City State ZIP Code
PHONE NUMBER
( )
FAX NUMBER
( )
EMAIL ADDRESS
9. I certify that I have direct knowledge of the work covering the time period outlined above. I certify under penalty of perjury, under the laws of the State of California,
that the information stated above is true and correct.
Date Signature Printed Name
Note: For information on the collection of personal information, please refer to the General Information and Instructions at
the beginning of this application package, under the heading “Collection of Personal Information.”
FOR CSLB USE ONLY
*ADDL-cert*
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CERTIFICATION OF WORK EXPERIENCE General Information (California)

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Completed 14 September 2021

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