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.
• $10.00 registration fee (check or money order) must accompany this application.
• Per NDCC 43-09-13.1, an apprentice electrician shall register with the ND State Electrical Board (NDSEB) within
the first six months of employment.
Name (First, Last)
Social Security Number
Date of Birth
Mailing Address
City
State
ZIP Code
Cell Phone Number
Email Address
Active Member of the Military
☐ No ☐ Yes
Spouse of a Member of the US Armed Forces or Reserves
☐ No ☐ Yes
Graduated from High School or Received a GED
☐ No ☐ Yes
Enrolled in a Power Limited Certification Program
☐ No ☐ Yes – List Program
Completed a Power Limited Program
☐ No ☐ Yes - Name of Program
Previously been Registered with the NDSEB
☐ No ☐ Yes
Ever Been Convicted of a Felony Under the Laws of this State or Any Other Jurisdiction?
☐ No ☐ Yes - Explain fully on a separate sheet of paper
Business Name of Present Employer
Name of ND Licensed Power Limited Electrician
Signature of ND Licensed Power Limited Electrician Under Whom you will be Serving Your Apprenticeship
I authorize investigation and certify that all statements contained in this application are true and accurate. In compliance with the Federal
Privacy Act of 1974, the disclosure of the individual’s social security number on this form is mandatory pursuant to North Dakota Century
Code 43-50-02. The individual’s social security number is used for identification and verification purposes. Penalty for the applicant not
including the social security number on their application will cause the application to not be processed.
Applicant Signature
Date
FOR OFFICE USE ONLY
Registration Number
Date Issued
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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