Fillable Each employer must verify work experience separately. Please (North Dakota State Electrical Board)

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Each employer must verify work experience separately. Please (North Dakota State Electrical Board)

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• Each employer must verify work experience separately. Please make copies as necessary.
• Verification of hours must be on this form to be acknowledged; any other forms of verification will not be accepted.
• Employment verification must accompany the Application for Electrician’s License by Exam (SFN 11858) or Application for
Power Limited Electrician’s License (SFN 61903).
Experience Requirements:
• Master: 10,000 hours (one year and 2,000 hours if ND Journeyman).
• Class B: 3,000 hours (farmstead and residential wiring only).
• Journeyman: 8,000 hours.
• Provisional Military Spouse: Experience for at least two of the four years preceding the date of application.
• Power Limited: 6,000 hours.
Name of Applicant (First, Last)
Last 4 of Social Security Number
Address
City
State
ZIP Code
Name of Electrical Contracting/Power Limited Business
Address
City
State
ZIP Code
Master/Power Limited Name
Master/Power Limited License Number
Position Held by Applicant
Dates of Employment
Start Date: End Date:
Total Hours of Electrical/Power Limited Work
Dates Above Taken from Payroll Records
☐ Yes ☐ No - Explain
Work Completed in the State of North Dakota
☐ Yes ☐ No - Attach a List of Jobs, if Jobs were Inspected by a Governmental Authority and if a License was Required
I declare under the penalties of perjury that this employment verification is to the best of my knowledge and belief a true, correct, and
complete record.
Signature of Contracting Master/Power Limited Electrician in Presence of Notary
Date
County
Before me, a notary public in and for said county/state, the NAMED PERSON below, personally appeared before me to be the same
person who executed the within and foregoing document and he/she acknowledges to me that he/she executed the same.
On this day:
Date
Name(s) of Individual Making Statement (By)
Affix Notary Stamp
Signature of Notary Public or Other Authorized Officer
Commission Expiration Date (if not listed on stamp)
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
EMPLOYMENT VERIFICATION
NORTH DAKOTA STATE ELECTRICAL BOARD
SFN 11845 (12-2020)
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Completed 21 April 2021

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