Fillable Complete all applicable items. Type or print legibly. (North Dakota State Electrical Board)

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• Complete all applicable items. Type or print legibly.
• Application must be completed each semester. (Maximum of two (2) semesters per calendar year).
I authorize investigation of all statements contained in this application. I understand that misrepresentation or omission of
facts called for in this application may be cause for denial.
Signature
Date
FOR OFFICE USE ONLY
Requirements Met
☐ No ☐ Yes - Number of Apprentices Approved
Approved By
Date
Check Number
Amount
Paid Date
APPLICATION FOR RELATED TRAINING SCHOLARSHIP FUNDS (PROVIDER)
NORTH DAKOTA STATE ELECTRICAL BOARD
SFN 61924 (12-2020)
Name of Provider
Mailing Address
City
State
ZIP Code
Telephone Number
Semester
☐ 1
st
Semester ☐ 2
nd
Semester
Number of Apprentices Enrolled this Semester in Related Training Program?
Related Training Program is Approved by the North Dakota State Electrical Board?
☐ No ☐ Yes – Provide North Dakota State Electrical Board Course Approval Number
All of the Following Requirements Must Be Met to Apply for Related Training Scholarship Funds
1. Record Providing Proof of Purchase of Education Materials for the Current Year’s Classes.
2. List of Apprentices Enrolled Per Semester in Related Training Program – See Page 2.
3. The Apprentice is a Resident of North Dakota. Provide a Complete Address - See Page 2.
4. The Apprentice Works in the Jurisdiction of the North Dakota State Electrical Board.
5. The Apprentice is Employed by a North Dakota Based Electrical Contractor – See Page 2.
6. The Apprentice Continuously Has Been Registered with the North Dakota State Electrical Board.
7. The Apprentice is Enrolled in a Board Approved Related Training Electrical Apprenticeship Program.
8. The Apprentice Must Have and Maintain a Minimum of a 2.5 Grade Point Average from the Previous Semester
(Including Incoming from High School) – See Page 2.
9. If an Apprentice Fails a Semester, Funds will not be Available for the Apprentice Until a 2.5 Grade Point Average is
achieved.
SFN 61924 (12-2020)
Page 2 of 2
Name of Apprentice (First, Last)
Apprentice Registration Number
Address
City
State
ZIP Code
Employer Business Name
GPA (Grade Point Average)
Name of Apprentice (First, Last)
Apprentice Registration Number
Address
City
State
ZIP Code
Employer Business Name
GPA (Grade Point Average)
Name of Apprentice (First, Last)
Apprentice Registration Number
Address
City
State
ZIP Code
Employer Business Name
GPA (Grade Point Average)
Name of Apprentice (First, Last)
Apprentice Registration Number
Address
City
State
ZIP Code
Employer Business Name
GPA (Grade Point Average)
Name of Apprentice (First, Last)
Apprentice Registration Number
Address
City
State
ZIP Code
Employer Business Name
GPA (Grade Point Average)
Name of Apprentice (First, Last)
Apprentice Registration Number
Address
City
State
ZIP Code
Employer Business Name
GPA (Grade Point Average)
Attach Additional Apprentice Information if Needed
Submit completed application to:
North Dakota State Electrical Board Phone: 701-328-9522
PO Box 7335 Fax: 701-328-9524
Bismarck, ND 58507 Email Address: electric@nd.gov
Website: www.ndseb.com
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Completed 21 April 2021

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