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ELECTRICIAN I hereby certify that I will not (North Dakota State Electrical Board)

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ELECTRICIAN
Name of Master/Class B Electrician
License Number
Address
City
State
ZIP Code
I hereby certify that I will not use my Master or Class B license for electrical contracting. If at any time in
the future I decide to engage in an electrical contracting business, I will contact the North Dakota State
Electrical Board for information regarding the proper forms to change status.
Signature of Master/Class B Electrician
Date
OWNER/REPRESENTATIVE
Note: Complete Below Only if Applicable
I understand the Master or Class B electrician named above is no longer contracting for the stated
electrical business.
Signature of Business Owner/Responsible Representative
Date
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 address: www.ndseb.com
APPLICATION FOR EXEMPTION TO ELECTRICAL CONTRACTING
NORTH DAKOTA STATE ELECTRICAL BOARD
SFN 61918 (12-2020)
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ELECTRICIAN I hereby certify that I will not (North Dakota State Electrical Board)

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Completed 21 April 2021

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