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Ulster County Electrical Licensing Board317 Shamrock Lane, Kingston, New York, 12401Telephone (845) 340-3537, Fax: (845) 340-3113Jeanne Walsh, ChairScott McCarthy, Vice-ChairJohn Parete, SecretaryJim SassChris PeoneTerry Munoz-WeaverTom NashDominick FerranteBrendan Masterson, Interim Commissioner DPWFOR OFFICE USE ONLYDate Received:Application Fee Rec’d: Y N1st Exam 2nd Exam GrandfatherAPPLICATION FOR AN ELECTRICIAN’S LICENSEType of license applied for:Master ElectricianGrandfatheryes noSee attached Schedule of FeesCOMPLETING THIS APPLICATION - Answer all questions fully and carefully. Print neatly and clearly using ink. Do not alter the form.Attach additional sheets if necessary in order to give complete and detailed information. All statements are subject to verification.APPLICANT / INDIVIDUALName: Phone:Address of Residence: Town:County: State:Zip:Email:CORPORATE OR BUSINESS NAME (D/B/A)Corporate or D/B/A:Address of Principal Office:Town: City:State: Zip:Individual Supervisor’s Name: Phone:Address: Town:County: State:Page 1 of 8Zip:Last Revised 1/28/21

DESCRIPTION OF EXPERIENCE: Be specific in listing your experience. You are responsible for submitting an accurate, adequate and cleardescription of your experience. Omissions or vagueness will not be resolved in your favor.EXPERIENCEAre you self-employed: YES NOIf no, name your present employer:Name: Address:How long have you worked for your present employer or been in your current business:Years MonthsWhat is your present position / title:What responsibilities do you have in your present position / title:How many years of apprenticeship did you serve in the trade:How many years as a journeyman did you serve in the trade:Have you had practical experience in the electrical field as a supervisor, foreman or superintendent?YESNOIf yes, please describe:How many workers did/do you have under your supervision:Have you trained apprentices:How many apprentices:YES NODo you carry any other electrical licenses? If so, name them with appropriate license number: (for all licenses listed,please provide a copy)Page 2 of 8Last Revised 1/28/21

Have you ever had an electrical license suspended, revoked, or other action taken and if so, the dispositionthereof:Give the name and address, as well as a description of the work, of five (5) electrical installations performed byyou in the last year:1)Customer Name: Contractor:Customer Address:Type of Work: Value/Cost of Job: Completion Date:Inspecting Agency Inspector’s Name2) Customer Name: Contractor:Customer Address:Type of Work: Value/Cost of Job: Completion Date:Inspecting Agency Inspector’s Name3) Customer Name: Contractor:Customer Address:Type of Work: Value/Cost of Job: Completion Date:Inspecting Agency Inspector’s Name4) Customer Name: Contractor:Customer Address:Type of Work: Value/Cost of Job: Completion Date:Inspecting Agency Inspector’s Name5) Customer Name: Contractor:Customer Address:Type of Work: Value/Cost of Job: Completion Date:Inspecting Agency Inspector’s NamePage 3 of 8Last Revised 1/28/21

Give the name of every person, firm or corporation with whom you have been employed for in the past five(5) years and state the nature of your employment (job title) in the electrical field. Begin with your most recent.(Use additional sheets if needed.)1)Employer Name: Nature of Employment:Employer Address:Your Title: Length of Employment (From/To Dates)2) Employer Name: Nature of Employment:Employer Address:Your Title: Length of Employment (From/To Dates)3) Employer Name: Nature of Employment:Employer Address:Your Title: Length of Employment (From/To Dates)4) Employer Name: Nature of Employment:Employer Address:Your Title: Length of Employment (From/To Dates)If your present employer is a firm or corporation, give the name and position of the person connected with the firmor corporation who is your immediate supervisor and to whom the Board may refer to for information concerningyou.NamePositionPhoneEDUCATIONFor College, University, Technical, Professional and other schools or special courses, please provide copies oftranscripts or certificates.School Attended Course/MajorDegree/Certification Year Graduated/EarnedSchool Attended Course/MajorDegree/Certification Year Graduated/EarnedPage 4 of 8Last Revised 1/28/21

School Attended Course/MajorDegree/Certification Year Graduated/EarnedSchool Attended Course/MajorDegree/Certification Year Graduated/EarnedREFERENCESList names of two individuals NOT related to you, or your trade that this board may obtain information concerningyou and your trade experience.NameAddressPhone E-MailOccupationNameAddressPhone E-MailOccupationGENERAL INFORMATIONAre you a member of any trade organization or association? YESNOIf yes, please list:Page 5 of 8Last Revised 1/28/21

Have you ever been convicted of a crime other than a traffic violation? YESNOIf yes, please explain:CHILD SUPPORT CERTIFICATIONAre you required to make child support payments? YES NO(Whether “yes” or “no”, the attached Child Support Form must be filled out)BY SIGNING BELOW, THE APPLICANT UNDERSTANDS THAT SUCH APPLICATION IS MADE UNDERPENALTIES OF PERJURY AND FURTHER ATTESTS THAT ALL THE INFORMATION SET FORTH ON THISAPPLICATION IS TRUE AND ANY FALSE OR MISLEADING INFORMATION IS PUNISHABLE AS A CLASS “A”MISDEMEANOR, SECTION 175.30 AND/OR SECTION 210.45 OF THE PENAL LAW AND SHALL MAKE THEAPPLICATION NULL AND VOID.BY SIGNING BELOW, THE APPLICANT AUTHORIZES THE COUNTY OF ULSTER AND THE ELECTRICALLICENSING BOARD OF THE COUNTY OF ULSTER TO INVESTIGATE THE FACTS SET FORTH IN THEAPPLICATION AS REQUIRED TO MAKE A DETERMINATION AS TO THE PERSON’S QUALIFICATIONS FORAN ELECTRICAL LICENSE.SIGNATUREDATE / /PRINT NAMESOCIAL SECURITY NUMBER - -* NEW YORK STATE GENERAL OBLIGATIONS LAW SECTION 3-503 REQUIRES THAT THE ATTACHEDDOCUMENT RELATING TO CHILD SUPPORT BE FILLED OUT AND NOTARIZED. * THE INTENTIONALSUBMISSION OF FALSE WRITTEN STATEMENTS FOR THE PURPOSE OF FRUSTRATING OR DEFEATINGPAYMENT OF SUPPORT IS PUNISHABLE PURSUANT TO SECTION 175.35 OF THE PENAL LAW. PERSONSWHO ARE FOUR MONTHS OR MORE IN ARREARS IN CHILD SUPPORT MAY BE SUBJECT TO SUSPENSIONOF THEIR BUSINESS, PROFESSIONAL AND DRIVER’S LICENSE.AFFADAVITI HEREBY CERTIFY THE ABOVE INFORMATION IS TRUE AND CORRECT. I WILL SAVE THE COUNTY OFULSTER AND ITS OFFICIALS HARMLESS FROM ANY LIABILITY FOR INJURY OR DAMAGE TO PERSONS ORPROPERTY FOR THE ISSUANCE OF ANY LICENCES, PERMITS OR PRIVILAGES GRANTED.APPLICANT'S SIGNATURE (must sign in front of a notary)Page 6 of 8DateLast Revised 1/28/21

ACKNOWLEDGEMENT TO BE COMPLETED BY A NOTARY PUBLICSTATE OF NEW YORKCOUNTY OF ULSTEROn this day of in the year 20 , before me, , PersonallyAppeared, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whosename is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/hercapacity, and that by his/her signature on the instrument, the individual executed the instrument.Notary -------------------------------------------For Ulster County Office Use Only:The Ulster County Board of Electrical Licensing hereby (grants) (denies) the license applied for in this application.Reason for denial:Chairman’s SignatureDatePage 7 of 8Last Revised 1/28/21

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Application ChecklistBefore you submit the application package, please review the following list to ensure that you have attached all requiredmaterials needed for review and consideration.-Have you completed all eight pages of the application, including two signatures, one in front of a notary?-Have you attached all additional information needed including copies of current licenses and transcripts?-Have you attached your check or money order for the APPLICATION fee payable to the Ulster County Commissioner ofFinance? Please see next page for fee chart, including application fee. (Licensing fee becomes payable when license is issued.)-Have you attached two passport sized photos? Incomplete applications will not be provided to the Board for review Please direct questions to:elb@co.ulster.ny.usor845-340-3537or317 Shamrock Lane, Kingston, NY, 12401Thank you!

Ulster County Electrical Licensing Board317 Shamrock Lane, Kingston, New York, 12401Telephone (845) 340-3537, Fax: (845) 340-3113Jim SassChris PeoneTerry Munoz-WeaverTom NashDominick FerranteJeanne Walsh, ChairScott McCarthy, Vice-ChairJohn Parete, SecretaryBrendan Masterson, Interim Commissioner DPWSCHEDULE OF FEES – ELECTRICAL BOARD(Adopted by Local Law No. 3 of 2019 & Electrical Licensing Board’s Rules and Regulations)All Fees Are Payable in Check OnlyApplication FeeExam FeeDecal Fee (each, first one is free) 50.00 125.00 10.00 Non- NYSResident100.0075.00 125.00125.00 10.0010.00 Master Electrician License Fee (Subject to Exam) 150.00 750.00 1,500.00Grandfathered Master Electrician License Fee 150.00 750.00 1,500.00Master Electrician Renewal Fee (Per Year)*All renewals subject to proof of refreshercourse within 12 months 75.00 75.00 350.00Late Fee (15 days after, Revocation after 30 days) 50.00 50.00 50.00Master Electrician License Shelving Fee 50.00 50.00 50.00Masters Certificate of Name Change Fee 150.00 150.00 150.00500.00 200.00 500.00200.00U.C. ResidentInitial Reciprocal Master Electrical License FeeReciprocal Master Electrical License Renewal*Per year in continuityn/an/aNYS Resident Failure to Comply Can Result in a Civil Penalty of 1,000.00 and/or Imprisonment of 15 days.Last Edited – 9/28/20

Ulster County Electrical Licensing Board . 317 Shamrock Lane, Kingston, New York, 12401 . elb@co.ulster.ny.us or 845-340-3537 or 317 Shamrock Lane, Kingston, NY, 12401 . Reciprocal Master Electrical License Renewal *Per year in continuity U.C. Resident 50.00 125.00 10.00 .