CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA 9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com 13A-11 (rev. 06/17)Certification of Work Experience 226 General Information CERTIFICATION OF WORK EXPERIENCE General Information This form must be filled in completely in order to document applicant222s work experience, or the application will bereturned for correction or completion. The qualifying individual on the application (as listed on Page 1 of the application)and certifier (a qualified and responsible person who verifies the experience in the classification for which the applicantis seeking licensure) must type or print neatly and legibly in black or dark blue ink 226 pencil is not acceptable.FORMS CONTAINING STRIKEOUTS OR MODIFICATIONS MAY NOT BE ACCEPTED.Corrections on the Certification of Work Experience forms must be initialed by the certifier.Original signatures are required 226 faxed, photocopied, or stamped signatures are not acceptable.All qualifying individuals and certifiers must be at least 18 years old.All Certification of Work Experience forms must be submitted with the application.The Certification of Work Experience form, when filed with an application, becomes the property of CSLB and is kept as a matter ofrecord. Keep a copy of the completed and signed form for your records 226 you may be asked to provide further documentationor testimony to verify your experience. A random three percent (3%) of applications are subject to review, and experience must beverifiable through payroll records and similar documents. CSLB staff may contact the certifier or other parties to verify experience.If you have ever served as a qualifier on a license in the classification for which you are now applying, you may not need tocomplete this form. However, if you are applying for a waiver of the examination pursuant to Business and Professions Code (BPC)sections 7065.1(b) or 7065.1(c), you do need to complete this form. (Please refer to CSLB222s website for more information on examwaivers.) NOTE: If you had a previous application that was denied on the basis of a lack of qualifying work experience,you must complete this form, regardless of whether or not you passed the examination.Anyone who knowingly procures or offers false or forged documents to be filed, registered, or recorded in any publicoffice in California is guilty of a felony. (Penal Code section 115)PART 1 226 QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION The qualifying individual (qualifier) must complete Part 1 in its entirety before the certifier completes Part 2. Lines 2 and 3 request the business name of company, license number of company, and company222s business street address of theplace where your experience was gained, which may or may not have been your employer.PART 2 226 WORK EXPERIENCE AND CERTIFICATION STATEMENT The certifier must complete Part 2 in its entirety after the qualifying individual has completed Part 1. The qualifying individual must document at least four (4) years of journeyman-level or higher experience in theclassification for which they are applying. The experience must have been obtained within the last 10 years.The qualifying individual222s work experience must have been completed at the level of journeyman, foreman, supervisingemployee, or contractor, as defined below (Title 16, California Code of Regulations [T16 CCR] section 825). Also defined beloware 223owner-builder224 and 223self-employed individual.224A 223journeyman224 is an experienced worker who is fully qualified (as opposed to a trainee) and is able to perform the tradewithout supervision, or a person who has completed an apprenticeship program. (T16 CCR section 825)A 223foreman224 or 223supervising employee224 is a person who has the knowledge and skills of a journeyman and directlysupervises construction projects.A 223contractor224 is an individual who is currently a licensed California contractor, a former licensed California contractor, or anout-of-state licensed contractor. A contractor has the skills necessary to manage the daily activities of a construction business,including field supervision.An 223owner-builder224 (a person who performs B-General Building classification work solely on their own property, pursuant to BPC section 7044) or a 223self-employed individual224 must have the knowledge and skills of a journeyman as listed above andthe skills necessary to manage the daily activities of a construction business, including field observation. Owner-builders mustcomplete and submit an Owner-Builder B-General Building Construction Project Experience form for each owner-builderproject on their own property.The Description of Classifications document may be used as a reference only and is available through a link on the Applicantspage of CSLB222s website.The certifier (a qualified, responsible person who is able to verify the work experience of the qualifier) must complete anddate and sign under the certification statement on line 9 at the bottom of the form. The certifier can be an employer, fellowemployee, journeyman, union representative, contractor, business associate, or a client if the applicant is/was self-employed. Thisform will help CSLB determine whether the qualifier has the experience necessary to become a qualified contractor.The certifier must have direct knowledge of the qualifier222s experience during the time period listed. 223Direct knowledge224means personal knowledge of the experience that does not depend on outside information or hearsay. The certifier must be able tocertify that the qualifier demonstrated a level of knowledge and skills expected of a journeyman or higher in the classification forwhich they are applying.Any licensee whose signature appears on a falsified Certification of Work Experience form, or who otherwise certifiesfalse or misleading experience claims submitted by an applicant to obtain a contractor license, will be subject todisciplinary action. (BPC section 7114.1) American LegalNet, Inc. www.FormsWorkFlow.com CONTRACTORS STATE LICENSE BOARD STATE OF CALIFORNIA 9821 Business Park Drive, Sacramento, CA 95827 Mailing Address: P.O. Box 26000, Sacramento, CA 95826 800.321.CSLB (2752) | www.cslb.ca.gov | CheckTheLicenseFirst.com 13A-11 (rev. 06/17)Certification of Work Experience Certification of Work Experience Please read the General Information on the previous page before beginning this form. The qualifying individual from Page 1 of the application must complete the information in Part 1 below; then, the certifier (person certifying the experience) must complete Part 2. The experience must be verifiable through payroll records or similar documents. If additional space is needed to list the trade duties, please attach a separate sheet that must also be signed under the same certification statement contained below in line 9. Use a separate form for each employer or work setting. If you need additional forms, please make a copy of this blank form or visit CSLB222s website to print the form. Please type or print neatly and legibly in black or dark blue ink 226 pencil is not acceptable. FORMS CONTAINING STRIKEOUTS OR MODIFICATIONS MAY NOT BE ACCEPTED. Corrections must be initialed by the certifier. PART 1 226 QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION The qualifying individual must complete Part 1 in its entirety before the certifier completes Part 2. 1. QUALIFIER222S FULL LEGAL NAME Last First Middle 2. BUSINESS NAME OF COMPANY WHERE EXPERIENCE WAS GAINED 226 OR, IF YOU WERE SELF-EMPLOYED, LEAVE THIS SPACE BLANK AND CHECK THIS BOX (If you checked the box, skip line 3 and go to line 4.) LICENSE NUMBER OF COMPANY WHERE EXPERIENCE WAS GAINED 3. COMPANY222S BUSINESS STREET ADDRESS Number/Street Only 226 NO P.O. Boxes City State ZIP Code 4. WAS THE EXPERIENCE OBTAINED WORKING ON YOUR OWN PROPERTY AS AN OWNER-BUILDER (see previous page for definition)? YesNo If you checked 223Yes224 above, use the Owner-Builder B-General Building Construction Project Experience form to provide information on completed projects. PART 2 226