Fillable SOUTH DAKOTA ELECTRICAL COMMISSION 2020 BIENNIAL RENEWAL FORM (South Dakota DLR)

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SOUTH DAKOTA ELECTRICAL COMMISSION 2020 BIENNIAL RENEWAL FORM (South Dakota DLR)

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South Dakota Department of Labor & Regulation (DLRA) aim to promote economic opportunity and financial security in the South Dakota. They support individuals and businesses through expert services, employment solutions and business practices.

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DLR Electrical Commission REV 07/2020
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
SOUTH DAKOTA ELECTRICAL COMMISSION
308 S. Pierre St. Pierre, SD 57501 | Tel: 605.773.3573 | Fax: 605.773.6213 | Email: Debbie.Dodson@state.sd.us
2020 BIENNIAL RENEWAL FORM
Licensee is required to satisfy continuing education requirements and child support arrearages prior to
submission of renewal form. All continuing education may be gained online for the 2020 renewal.
LICENSEE INFORMATION:
Complete ALL contact information (all fields are required unless otherwise indicated)
Name: ______________________________________________________________________________________
Corr
espondence Address: ______________________________________________________________________
City:
__________________________ State: ______ Zip:__________ Personal Tel.: ____________________
Email: _
__________________________________________________________________________
Do you prefer to receive correspondence by (please check one box): Mail or Email
Renewal forms, tidbits and other commission distributions will be sent via email only.
OPTIONAL: Business Cell: ____________________ Business Phone: ____________________
Business numbers are public information
RENEWAL INFORMATION:
Check box for each license to be renewed. Write license number on corresponding line.
Electrical Inspector ($40) License: _______________ License: ____________________
Electrical Contractor ($100) License: _______________ License: ____________________
Inactive EC ($40) License: _______________ License: ____________________
Class B ($40) License: _______________
Journeyman ($40)
Inactive JM ($40)
Apprentice ($20)
501(D) ($40)
License: ____________________
Inactive Class B($40) License: _______________ Inactive 501 (D) ($40) License: ____________________
Reinstatement Fee (renewal after June 30) ($50) License: ____________________
TOTAL AMOUNT DUE: _______
Have you ever been convicted of, or pled guilty or nolo contendere to a crime of violence as defined under SDCL §22-1-2?
Yes No If yes, explain on a separate sheet giving date, place, and full particulars; attach as part of this application.
PAYMENT METHOD
Pay by (please check one): Check Money Order Credit Card
(Make checks or money orders payable to the Electrical Commission. To pay by credit card, please fill out the information below.)
Charge my credit card $_________________ Card Number: ____________________________________________
Expiration Date ____/____ 3-Digit Security Code: ______ SIGNATURE: ________________________________________
I solemnly swear the statements made herein are true and correct to the best of my knowledge and belief. I also certify I understand:
• If this application is not signed and dated or include required fees, the application will be returned to me.
• Application and license fees are not pro-rated and are non-refundable.
SIGNATURE: ______________________________________________________________ DATE: ____________________
RETURN ENTIRE
APPLICATION
DUE
JUNE 30, 2020
✔
$ 50.00
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SOUTH DAKOTA ELECTRICAL COMMISSION 2020 BIENNIAL RENEWAL FORM (South Dakota DLR)

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Completed 21 August 2020

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