State of New Jersey
DEPARTMENT OF LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
BOARD OF EXAMINERS OF ELECTRICAL CONTRACTORS
124 HALSEY STREET, 6TH FLOOR, P.O. BOX 45006
NEWARK, NEW JERSEY 07101
973-504-6410
Work Experience Certification
(To be completed by the individual named as a reference.)
(Please type or print clearly.)
___________________________________________ ________________________________________
Name of applicant Name of reference and company name
___________________________________________ ________________________________________
Applicant's home address Reference's home or business address
___________________________________________ ________________________________________
Home telephone number (include area code) Reference's telephone number (include area code)
___________________________________________ ________________________________________
E-mail address E-mail address
1. The above applicant has asked you to certify his or her qualifications (See N.J.A.C.13:31-2.1, Qualifications of Applicants, on the
reverse side) to take the examination for an Electrical Contractor's license. Please provide the exact dates of his or her employment.
A. From _________/ _______/ ______ to _______/ _______ / ________
month day year month day year
B. Average number of hours the applicant worked per week: _________
C. Please explain his or her electrical installation experience. (Use additional paper if necessary.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. Are you an electrical contractor in any other state or province? Yes No
If "YES," in what state or province are you a licensee? _______________What is your license number? __________________
If you are a licensed electrical contractor in New Jersey, and you hold a Business Permit, please provide an impression of your
Business Permit Seal and please provide your New Jersey license number. __________________________________________
SEAL
3. I hereby certify that I am the ____________________________________________ of_________________________________
Reference/Title Company
and that I have personal knowledge of the qualifications of the applicant, and that he or she worked for me for _________________
Length of time (years/months)
gaining practical experience working with tools in the installation, alteration or repair of wiring for electrical light, heat or power.
___________________________________________ _____________________________________
Signature of reference Date
