Master Electrician or
Special Electrician
Experience Verification Form
Applicant Name: _____________________________________________________________________
(Print)
Electrician Business where applicant was supervised: _________________________________________
(Print)
Instructions to Applicant
Please print your name and the name of the company for which you worked and give this form to EACH
licensee that you have worked for during the timeframe you are claiming as qualifying experience.
Instructions to Supervisor/Licensee
The above Applicant has applied to become a Licensed Master Electrician (ME) or Licensed Special
Electrician (SE) with the New York City Department of Buildings. The Applicant indicated in his or her
application that he or she worked under your supervision while working for the above business/firm and
that you were licensed to perform such work during that employment.
If the Applicant had more than one direct supervisor, please photocopy this verification form and have
each supervisor SEPARATELY complete their verification and fax and mail it back to this office as
instructed below.
Please read and follow these directions before filling out the form:
• All sections of this verification form must be completed by the ME or SE whom directly supervised the
Applicant. It MAY NOT be completed by an Office Manager or Personnel/Human Resources
employee.
• The ME or SE and NOT THE APPLICANT must complete all portions of this verification form. It must
be signed, sealed and notarized.
• Please list ONLY the job duties the Applicant performed under your direct supervision.
• Answer every question or indicate “N/A” (not applicable) when the question does not apply to you.
• Please attach copies of the Electrician licenses you currently hold and held when the applicant was
under your supervision.
• If the licensee supervised applicant at more than one business please photocopy and fill out
additional verification forms.
• Once completed, please mail the original notarized verification form(s) to the applicant who will then
submit the forms to the Department of Buildings.
YOUR FAILURE TO RESPOND MAY RESULT IN THE APPLICANT’S DISQUALIFICATION FOR THIS
LICENSE, AND/OR YOU BEING REQUIRED TO TESTIFY IN FRONT OF THE ELECTRICAL LICENSE
BOARD.
Applicant’s Name __________________________ Licensee Initial here _________ 1
Master Electrician or
Special Electrician
Experience Verification Form
LICENSEE INFORMATION:
Your name: __________________________________________________________________________
Your current job title: ___________________________________________________________________
Your current telephone number: _________________________ Fax number: ____________________
Your title when supervising the Applicant (if different) _________________________________________
Have you held a NYC ME or SE? Yes No
If yes, list License #:_________________ Date of Issuance: __________ Date of Expiration: __________
Since your license was issued, was there any period during which your license(s) was not active?
Yes No
If yes, list the time period(s) when your license was inactive: _________________
Current Electrician Business (if different):
____________________________________________________________________________________
Please list any additional Electrician license(s) you hold (not in NYC) or held at the time you supervised
the applicant and the jurisdiction of licensure. (please attach copies):
License #:_________________ Jurisdiction of Issuance: ______________ Date of Issuance: _______
Date of Expiration: _________
License #:_________________ Jurisdiction of Issuance: ______________ Date of Issuance: _______
Date of Expiration: _________
Since your license(s) was issued, was there any period when your license(s) was not active?
Yes No
If yes, list the License#(s) and the time period(s) when your license was inactive: ___________________
APPLICANT’S EMPLOYMENT INFORMATION:
If you supervised the applicant over more than one time frame, please make additional copies of this page for each
supervision period or if the applicant was employed at your firm for multiple time periods, please make additional
copies for each employment period. Number # of additional pages: _______
Employed From: _____________ To: ____________
Did you directly supervise the Applicant? Yes No
If no, please explain here:
Were you licensed as an Electrician while the Applicant was under your supervision? Yes No
If no, please explain here:
Applicant’s Name __________________________ Licensee Initial here _________ 2
Master Electrician or
Special Electrician
Experience Verification Form
While under your direct and continuing supervision, was the applicant employed on a full-time basis in the
installation, alteration and repair of wiring and appliances for electric light, heat and power in or on
buildings or comparable facilities? Full time employment is considered 35-40 hours per week.
Yes No
If no, please explain here:
Was the applicant under your payroll (or the payroll of your employer)? Yes No
If not, please explain here and attach documentation that would reflect the relationship you and/or your
company had with the applicant’s employer during your supervision.
Please fill out chart on page 4.
Are you aware of any acts or omissions by the applicant that may reflect on the applicant’s moral
character? Yes No
Explain:
Applicant’s Name __________________________ Licensee Initial here _________ 3
Master Electrician or
Special Electrician
Experience Verification Form
For the time the Applicant was under your supervision, please provide the required information below:
You must provide a detailed description of the work the Applicant performed in each title. Just stating that the applicant
worked in “design, alteration and repair” is not enough. You must clearly describe the work (e.g. general wiring, metering
work, etc.) the applicant performed during his or her employment and the types of jobs on which the Applicant worked
(new buildings, gut renovation, lighting, sidewalk sheds, and premises/permit information by way of example)
Applicant’s Time period Wages per Hours per week Describe type of work performed:
Title hour (Please describe ALL types of work and provide examples)
Applicant’s Name __________________________ Licensee Initial here _________ 4
Master Electrician or
Special Electrician
Experience Verification Form
Additional Comments regarding Applicant’s experience and ability:
Please note: Failure to completely and accurately provide a detailed description of the applicant’s work
may result in your testimony and questioning by the Electrical License Board.
I have voluntarily provided the attached information on the verification form regarding this Applicant. I attest
and affirm to the truthfulness of my statements and fully understand that any false statement or any material
omission made in connection with this document is sufficient cause for The City Of New York to deny the
license being sought by the applicant. I also understand and agree that that any false statement or any
material omission made in connection with this document is sufficient cause for the City Of New York to
invalidate, rescind or revoke any and all licenses and/or registrations that were issued to me under the
jurisdiction of the NYC Department of Buildings. In addition, I understand that any such false submission
may subject me to criminal charges, including, but not limited to, New York State Penal Law sections 175.35
(offering a false statement for filing) and 240.40 (sworn false statement) and/or title 18 U.S.C section 1001
(false or fraudulent statement), which may result in imprisonment, a fine, or both.
Print your name: ____________________________________
Your signature: _____________________________________ Date: _______________
STATE OF ____________________)
COUNTY OF __________________) SS:
On the ____________ day of _________________ in the year __________, the undersigned,
_____________________________, personally known to me or proved to me on the basis of satisfactory
evidence, personally appeared before me and subscribed his/her name to the above Verification and, after
being duly sworn upon his oath, says that the facts alleged in the foregoing affidavit are true.
_________________________
(Notary Public)
Licensee (Place Seal) here:
Applicant’s Name __________________________ Licensee Initial here _________ 5
