Application for Electrical Apprentice or Fire Alarm ...
Application for Electrical Apprentice or Fire Alarm Specialty Technician Apprentice
Michigan Department of Licensing and Regulatory Affairs
Bureau of Construction Codes / Licensing Division
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P.O. Box 30255, Lansing, MI 48909
517-241-9316
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This form can be completed by
tabbing to each field and typing
in the required information.
Authority:
Penalty:
2016 PA 407
Failure to provide the information may result in denial of your request.
117
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Agency Use Only
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations
are available upon request to individuals with disabilities.
Note: A veteran providing satisfactory proof of separation from the armed forces of the United States under ¡°honorable¡± or ¡°general under
honorable conditions¡± is exempt from the initial license fee. For consideration, please attach a copy of either a DD-214, and/or DD-215 to your
application.
General Instructions:
? Apply and pay online at
Or
?
¡õ Veteran exemption.
Mail completed application, required documents, and $15.00 license fee to the address listed above.
Please Check One: ¡õ Electrical Apprentice
¡õ Fire Alarm Specialty Technician Apprentice
Applicant Information
NAME (Last Name, First Name, Middle Initial)
SOCIAL SECURITY NUMBER
ADDRESS
COUNTY
CITY
TOWNSHIP
STATE
ZIP CODE
TELEPHONE NUMBER (Include Area Code)
E-MAIL ADDRESS
Sponsoring Employer Information - Locally licensed contractors must provide a copy of current license with this application
SPONSORING EMPLOYER
HIRE DATE OF APPLICANT
CONTRACTOR¡¯S LICENSE NUMBER
MASTER(62)/ SPECIALITY TECH(52) LICENSE NUMBER
Certification and Signature of Sponsoring Employer
Electrical Apprentice: For an electrical apprentice, the sponsoring employer¡¯s signature must be either the contractor of record or qualifying master.
Fire Alarm Specialty Technician Apprentice: For a fire alarm specialty technician apprentice, the sponsoring employer¡¯s signature must be either the
contractor of record or qualifying fire alarm specialty technician.
I certify the information is true and accurate to the best of my knowledge.
PRINTED NAME OF SPONSORING EMPLOYER
SIGNATURE OF SPONSORING EMPLOYER
BCC-0704 (Rev. 07/17) Page 1 of 2
Certification and Signature of Approved Related Technical Instruction Provider
I certify that ___________________________________________________ is currently participating in an electrical or fire alarm
(Printed Name of Applicant)
training program approved by the Electrical Administrative Board.
RELATED TECHNICAL INSTRUCTION PROVIDER (e.g. college, trade, labor organization etc.)
PRINTED NAME OF AUTHORIZED REPRESENTATIVE
PHONE NUMBER
SIGNATURE OF AUTHORIZED REPRESENTATIVE
DATE
I understand that I am responsible for maintaining a chronological record of my employment as an electrical apprentice or fire alarm
specialty technician apprentice and that I must submit proof of my employment when requested by the licensing authority.
Certification and Signature of Applicant
I certify the information provided is true and accurate to the best of my ability. I further understand fraud or deceit in obtaining registration
is grounds for administrative action in accordance with the act.
APPLICANT¡¯S SIGNATURE
BCC-0704 (Rev. 07/17) Page 2 of 2
DATE
................
................
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