REV 07/2019
SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION
SOUTH DAKOTA ELECTRICAL COMMISSION
308 S. Pierre St., Pierre, SD 57501
Tel: 605.773.3573. Toll-Free: 1.800.233.7765 Fax: 605.773.6213 electrical.sd.gov
APPRENTICE LICENSE APPLICATION
INSTRUCTIONS
This application must be filled out electronically or legibly printed in ink. Complete all spaces. If the question does not apply, write
“none” in the blank space. Failure to answer questions may cause the application to be returned. All licenses expire June 30 of the
even numbered years. The application process takes approximately 30 days.
Part A
Name __________________________________________________________ SSN __________________________**
Mailing Address _______________________________________________City __________________________________
State ______ Zip _________ Preferred Tel: (______)_______ - _________ Alternate Tel: (______)_______ - _________
Email address ____________________________________________ Notification Preference: email mail
Present Employer ____________________________________ Their License No. ______________________________
**The disclosure of the applicant’s Social Security Number (SSN) is mandatory pursuant to 42 USCA 666, Title IV-D of the Social Security Act. The
Electrical Commission will keep the applicant’s SSN confidential.
Part B
Have you ever been issued an electrical license from another State? Yes No
If yes, State _______ Type __________________ License#_____________ In force from _________ to__________
Have you ever had a license denied or revoked? Yes No If yes, please state reason below:
Ensure your application includes:
Signature and Date
Required $20 Fee, Payable to “South Dakota Electrical Commission”
By my signature below, I do solemnly swear the statements made herein are true and correct to the best of my knowledge and
belief. I also certify that I understand:
• If this application is not signed and dated or include required fees, the application will be returned to me.
• My SSN may be provided to the Department of Social Services for use in administering Title IV-D of the Social Security Act.
• Application and license fees are not pro-rated and are non-refundable
Signature ____________________________________________________ Date _____/______/________
To Submit: Mail to the South Dakota Electrical Commission at the address on the top of this application.
Have you ever been convicted of, or pled guilty or nolo contendere to a crime of violence as defined under §22-1-2?
Yes No
If yes, submit a separate sheet giving date, place, and full particulars and attach as part of this
