The Commonwealth of Massachusetts State Examiners of ...

The Commonwealth of Massachusetts State Examiners of Electricians

1000 Washington Street Suite 710 ? Boston, Massachusetts 02118-6100

EMPLOYMENT CERTIFICATION (form 272)

To the State Examiners of Electricians: In connection with my application for examination for a journeyman electrician/ Systems technician license, I submit the following certificate to vouch for my statements as to my experience.

______________________________________________ _____________________________________________________________________

(Signature of Applicant)

(Date)

(Address)

The following information is to be filled out by a licensed electrician. (Please Print)

To the State Examiners of Electricians: Subject to the penalties set forth in Section 5 of Chapter 141 of the General Laws of Massachusetts, I hereby subscribe to and vouch for the statement made by

______________________________________________________________ (______)-_________________-__________________

(Name of Applicant)

(Telephone Number)

in his application for examination for a Journeyman electrician/Systems technician license, that he was employed by

_________________________________________________ ______________________________________________________________

(Name of Employer)

(Address of Employer)

from _____/_____/19___

to ____/____/19____

(Date of Employment)

(Date of this certificate or of termination) (Separate sheets must be completed for each date range)

in the capacity of__El_ec_tr_ic_ia_n_A_pp_r_en_ti_ce____________________________________________________________________________________ (Electrician/ Technician Apprentice, or other Rating please specify)

and that this employment amounted to a total accumulated time of _______years and _______months or_______ hours

Such employment consisted of installing r_ep_a_ir_in_g _or_m_a_in_ta_in_in_g_w_ir_es_, _co_n_du_it_s,_a_p_pa_ra_tu_s_, d_e_v_ice_s_, f_ix_tu_re_s_o_r o_th_e_r _ap_p_lia_n_ce_s_u_se_d_f_or_li_gh_t,_h_e_at_, p_o_w_er_, f_ir_e _w_ar_ni_ng_o_r_s_ec_u_rit_y _sy_s_tems. (Describe nature of work in detail) on a (check one) full time __X____ part time _____ basis and ___1_00_______% consisted of work for which a license is required by law, and was performed under the direct personal supervision of a licensed journeyman/systems technician.

(If work was "part-time" explain in detail on the reverse side of this sheet listing all positions held by the applicant within the dates stated above including names, addresses and dates.)

Required: Can you produce payroll records for this person? Yes____ No____

____________________________________________________________ _________________________________________________

(Name of Applicant's Employer)

(Signature of Licensed Professional)

Required: Responsible supervising License holder

Journeyman/Technician License No_______________

(______) ______________ - _____________________ Telephone Number

Master/Systems Contractor license holder

License no.

(_______) _____________ - _____________________ Telephone Number

GENERAL LAWS, TER. ED. CHAPTER 141 Section 9. Any person applying for a journeyman/technician license and making any misstatement as to his experience or other qualifications, or any person, firm or corporation subscribing to or vouching for any such misstatement, shall be subject to the penalties set forth in Section 5. (A fine of not less than ten or more than one hundred. Subsequent offenses. A fine of $50 to $500 or imprisonment for six months or both.)

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