CITC Apprentice Request for Electrical Affidavits of Experience

I(Required)

am/was a registered CITC Electrical 01, 02, or 06 apprentice. I am requesting my affidavit(s) of experience for the following (circle one) time period:

My WA Electrical Trainee License number is:(Required)

I attest that I have not requested affidavits from my employer for the time period above. I understand that I cannot submit duplicate or overlapping affidavits for the same time periods to L&I Electrical Licensing, and that while I am a CITC apprentice, I will not and cannot request electrical affidavits of experience from my employers.

From(Required)

To(Required)

During the above time period, have you worked in the State of Idaho?(Required)

Yes

If yes, please list the specific dates:(Required)

Reason for requesting an affidavit:

I have enough OJT hours to apply for the journeyman electrician exam

I have enough OJT hours to apply for a work alone card (commercial 01 program only)

I am renewing my electrical trainee card, which expires on

I have suspended, withdrawn, or transferred from the CITC apprenticeship

Please:(Required)

Mail the affidavit(s) to my home address on file

Call me to pick up the affidavit(s) at the CITC main office in Bellevue

Expiring Date(Required)

I authorize the WA Dept of L&I, Electrical Program, permission to release any information pertaining to my electrical records to CITC for the purposes of issuing my affidavits of experience.

Signed:(Required)

Date:(Required)