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2. Instructions to Applicant:

   • Complete this Application for Electrical Registration and return to the City Clerk’s Office at 208 S. Rapp Ave., Columbia, IL 62236, or email to cmaness@columbiaillinois.com or returned by fax at (618) 281-5477.
   • Minimum Requirements: Two years formal instruction or 4 years (8,000 hours) construction work experience.
   • The office of the Electrical Inspector will contact the applicant.
   • The current registration fee is $25.00 to be paid at the City Clerk’s Office by cash, by check (payable to the City of Columbia), or online by credit/debit at www.columbiaillinois.com. (The online option has an additional fee of $1.50.)
   • Annual registration fees due May 1 are required to maintain registration. If an electrical contractor fails to pay the registration fee for 2 or more consecutive years, the registration will be revoked and the contractor will have to complete the entire application process to regain registration.

4. Company Information
6. Company Name*
8. Company Address*
10. Company Phone #*
11. Company Email*
13. Applicant Information
15. Name*
17. Address*
19. Phone #*
20. Email*
22. Have you ever carried an electrical license? *

    1. Yes

    1. No
23. If so, where?
25. State the type or grade of license;
27. In force from:
28. to
30. Are you registered as an electrical contractor in any other city? *

    1. Yes

    1. No
31. If so, where?
33. In force from:
34. to
36. Was the license or registration obtained by examination? *

    1. Yes

    1. No
38. Have you ever had an electrical license or registration revoked?*

    1. Yes

    1. No
40. If so, by whom? Also state the reason why.
42. If the items below are not completed we will not be able to complete your registration. Please complete all areas, in full, to the best of your ability.
44. PART I: Schooling and formal instruction directly related to electrical theory and practical applications involving electrical wiring and equipment.
46. A. Vocational or Trade School
48. Name
50. Address
52. Date Started
    Date Started
53. Date Completed
    Date Completed
54. Name of Course
56. B. College Training
58. Name
60. Address
62. Date Started
    Date Started
63. Date Completed
    Date Completed
65. C. Military Training
67. Branch
69. Location
71. Date Started
    Date Started
72. Date Completed
    Date Completed
74. D. Other
76. Explain
78. Are you familiar with the National Electrical Code?

    1. Yes

    1. No
80. Part II: Construction Work Experience
82. A. Owner or Office of an Electrical Contracting Company
84. Name
86. Mailing Address
88. Date Started
    Date Started
89. Date Completed
    Date Completed
91. Position(s) Held
93. B. Supervisor/Foreman
95. Name
97. Mailing Address
99. Date Started
    Date Started
100. Date Completed
     Date Completed
102. C. Apprentice on Job Training
104. Name
106. Mailing Address
108. Date Started
     Date Started
109. Date Completed
     Date Completed
111. D. Approximate years experience in the following types of work.
113. Residential Wiring*
114. Commercial Wiring*
116. Industrial Wiring*
117. Maintenance*
119. NOTE: The City of Columbia Electrical Board Reserves the right to verify your work experience by examination, written or oral.
121. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*

     1. I agree
123. Signature*
124. Date*
     Date
Leave This Blank:


126. 1. Receive an email copy of this form.
127. Email address

     This field is not part of the form submission.

128. Submit

* indicates a required field