HomeMy WebLinkAbout3/22/2002 9102 ITY OF IOWA CITY, IOWA
APPLICATION FOR AN ELECTRICIAN'S LICENSE
This application must be filled out completely and in detail
and shall be on file with the Building Official.
CITY OF I0 WA CITY
Type of license for which you are applying:
NAME
[~' Journeyman
[] Master's
[] Restricted
[] Maintenance
RESIDENCE ADDRESS
CITY ~ ~.,~K ~ .' ~,~
TELEPHONE NUMBER
PRESENT EMPLOYER /~/ct,~,,c
ADDRESS OF EMPLOYER
STATE :~f?., ,~..," ZiP
SOCIAL SECURITY NO. L.{ 72'-2'~-'
AGE /~ I- DATE OF BIRTH fl- ~'~' ~'-'~ BIRTHPLACEci-~) o~-~,~ ~)~State .....
Have you ever had an electrical license revoked?
And if so, give reasons:
By whom?
Have you previously been examined for an Electrical License by this Board?.
If so, state type and results of examination:
Was it approved?
Have you previous made an application for a City of Iowa City Electrical License? /~/[~
(over)
CIVIC CENTER · 410 EAST WASHINGTON STREET · IOWA CITY, IOWA 52240 ° (319) 356-5000
ELECTRICIAN'S LICENSE APPLICATION - CITY OF IOWA CITY Page 2
ELECTRICAL EMPLOYMENT RECORDS
(Give previous and present employers and complete address.)
EMPLOYER
DATES EMPLOYED: From
Type of Electrical Work
COMPLETE ADDRESS
EMPLOYER
DATES EMPLOYED: From
Type of Electrical Work
EMPLOYER
DATES EMPLOYED: From
Type of Electrical Work
/
COMPLETE ADDRESS
COMPLETE ADDRESS
to ~
~,~,~ - ~..;.~ ~.?~.
EMPLOYER COMPLETE ADDRESS
DATES EMPLOYED: From /~'~'~ to
Type of Electrical Work
If this application is approved by the City, you will be notified as to when you will take your examination.
The foregoing statements are true and correct to the best of my knowledge and belief.
Sig/na~ure ~/Applicant[
hisblg\electlic.app
/- 25- o~
Date