REQUIREMENTS FOR EXAMINATION AND LICENSE - ELECTRICIANS & PLUMBERS
Visit our website at: cca.hawaii.gov/pvl
THE LAW No person shall act or assume to act as a journey worker electrician, journey worker specialty electrician,
supervising electrician, supervising specialty electrician, journey worker plumber, master plumber, maintenance
electrician, journey worker industrial electrician, or supervising industrial electrician, or advertise or hold the
person's self out as an electrician or plumber, without a license previously obtained in compliance with Chapter
448E, Hawaii Revised Statutes and Chapter 16-80, Hawaii Administrative Rules.
The electrician's or plumber's license DOES NOT allow one to contract to perform electrical or plumbing work. A
contractor's license pursuant to 444, HRS is required.
QUALIFYING FOR THE EXAMINATION
IMPORTANT: Hawaii does not reciprocate with any jurisdiction. Incomplete or deficient applications will delay
processing.
TYPE OF LICENSE
Journey Worker Electrician. . . . . . . . . . . . . . . . . . . . .
LICENSE
TYPE CODE REQUIREMENTS
EJ. . . . . . .
5 years but not less than 10,000 hours in residential
or commercial wiring and satisfactory
completion, accepted by a University of Hawaii
Community College offering an appropriate
program of study, of 240 hours of electrical
academic coursework.
Supervising Electrician. . . . . . . . . . . . . . . . . . . . . . . . . ES. . . . . . . 4 years experience as a licensed journey worker
electrician or equivalent.
Journey Worker Industrial Electrician. . . . . . . . . . . EJI. . . . . . . 4 years but not less than 8,000 hours in industrial
electrical work and satisfactory completion,
accepted by a University of Hawaii Community
College offering an appropriate program of
study, of 200 hours of electrical academic
coursework.
Supervising Industrial Electrician. . . . . . . . . . . . . . . ESI. . . . . . . 3 years experience as a licensed journey worker
industrial electrician or equivalent.
EP-00 0318R
(CONTINUED ON PAGE 2)
Act 35, SLH 2010 requires all journey worker and maintenance electricians to provide verification of completion of
electrical academic coursework conducted at or accepted by a University of Hawaii Community College. (See
below for the number of hours required for each electrician classification).
TRADE EXPERIENCE
REQUIRED
EXPERIENCE
VERIFICATION
FORMS REQUIRED
All applicants shall meet the requirements in effect at the time of application. Applicants shall apply, be qualified
by the Board of Electricians and Plumbers, and attain a passing score on Hawaii's licensure examination.
Submit completed and notarized forms "Experience Verification(s) - Electrician Only" OR "Experience Verification(s)
- Plumber Only" from EACH licensed electrician OR plumber under whom you received your experience/training.
NOTE: A license as an electrical or plumbing contractor is not acceptable on this form, provided that if the state
where you attained your experience does not require licensure as a journey worker, supervising or master
electrician or plumber, but only requires a contractor's license, the Board will accept a notarized Experience
Verification form signed by the licensed contractor. In these cases, the applicant shall submit verification of the
contractor's license that includes the effective dates of licensure which shall coincide with the dates being verified.
ELECTRICIANS
ONLY
(CONTINUED ON PAGE 3)
-2-
Pursuant to 448E-5(b), all journey worker & maintenance electrician classifications are subject to an educational
component. The electrical academic coursework outlined below shall be conducted by or accepted by a
University of Hawaii Community College. This means that a Hawaii Community College must review and deem
your electrical coursework for the appropriate electrician classification as equivalent to that being taught by their
institution.
Maintenance Electrician. . . . . . . . . . . . . . . . . . . . . . . EM. . . . . .
1 year of electrical maintenance work and
satisfactory completion, accepted by a
University of Hawaii Community College offering
an appropriate program of study, of 80 hours of
electrical academic coursework or 2 years of
schooling in the trade with not less than 1,000
hours of hands-on lab exercises.
Journey Worker Plumber. . . . . . . . . . . . . . . . . . . . . . PJ. . . . . . . 5 years but not less than 10,000 hours of
plumbing work in compliance with the Uniform
Plumbing Code (UPC).
Master Plumber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PM. . . . . . Registered as a licensed journey worker plumber in
this or another state for at least 2 years.
ELECTRICAL
COURSEWORK
REQUIRED FOR
ELECTRICIANS
ONLY
To obtain the required electrical coursework, contact the HCC or participating community colleges directly for
their course schedule.
OAHU
Office of Continuing Education
Honolulu Community College
874 Dillingham Boulevard
Honolulu, HI 96817
Phone: (808)845-9296
Email: [email protected]
HAWAII
EDvance
1175 Manono St.
Bldg. 379-A, Room 3
Hilo, HI 96720
Phone: (808)934-2700
Fax: (808)934-2701
Email: [email protected]
Website:
https://edvance.hawaii.hawaii.edu
MAUI
EdVenture
310 W. Ka'ahumanu Ave.
Kahului, HI 96732
Phone: (808)984-3231
Fax: (808)984-3874
Email: [email protected]
Website: http://maui.hawaii.edu/edventure
KAUAI
Kauai Community College
Office of Continuing Education & Training
3-1901 Kaumualii Hwy.
Lihue, HI 96766
Phone: (808)245-8318
Website: https://sites.google.com/a/hawaii.edu/office-of-
continuing-education
2 years experience as a licensed journey worker
specialty electrician or equivalent.
ESS. . . . . .Supervising Specialty Electrician. . . . . . . . . . . . . . .
3 years but not less than 6,000 hours in the trade
and satisfactory completion, accepted by a
University of Hawaii Community College offering
an appropriate program of study, of 120 hours of
electrical academic coursework.
EJS. . . . . . Journey Worker Specialty Electrician. . . . . . . . . . .
For a master plumber, equivalent experience in the trade means having been licensed as a journey worker or
master level plumber for at least 2 years in another county, state, or country when requirements for licensure are
substantially equivalent to those in force in this State.
For supervising electrician categories, equivalent experience in the trade means having been "licensed" as a
journey worker or supervising level electrician (EJ, EJS, ESS) for at least 4 years in another county, state, or country
when requirements for licensure are substantially equivalent to those in force in this state.
LEEWARD
Office of Continuing Education &
Workforce Development
96-045 Ala 'Ike, Room CE-101
Pearl City, HI 96782
Phone: (808)455-0477
Fax: (808)453-6730
Email: [email protected]
Website: http://www.ocewd.org
-3-
NOTE: The Board is unable to accept electrical academic coursework that has not been reviewed and approved
by a University of Hawaii Community College.
Email: [email protected]
OR
Mail to: Honolulu Community College
Attention: Non Credit Registration Office
874 Dillingham Boulevard
Honolulu, HI 96817
Verification of Completion: Honolulu Community College requires official verification of completion
documents that you completed training through an apprenticeship program, collegiate program of study,
Military training, or a combination of each.
(CONTINUED ON PAGE 4)
NOTICE: Before submitting your coursework for review, check if your coursework has been approved on the
Approved Academic Coursework Required by HRS §448E-5 Minimum Requirements (b) list at:
http://cca.hawaii.gov/pvl/news-releases/ep_announcement.
For review of educational coursework not obtained at or not previously approved by the Hawaii Community
College system, provide the following:
1.
2.
3.
4.
Program and Course Description: Provide detailed program and course descriptions from your respective
training program. These documents are used to determine if the appropriate electrical content areas as
defined by Hawaii Revised Statutes, §448E-5(b), minimum requirements, are included as part of the training
program.
Provide your contact information: Name, primary phone, mailing address, email address.
Submit all documents to:
ELECTRICAL
COURSEWORK
REQUIRED FOR
ELECTRICIANS
ONLY
(cont'd)
(CONTINUED ON PAGE 5)
-4-
Grounding I
20 hours
X X X
Grounding II
10 hours
X X
Grounding III
10 hours
X
Motor and Motor Control
Maintenance
20 hours
X
Motors
30 hours
X X
Motor Control
30 hours
X X
Transformers
30 hours
X X
Test Instruments
10 hours
X X
Configuring and
Installing Structured
Cabling Systems
20 hours
X
Codeology, Residential
and Commercial
20 hours
X
XXX
Codeology, Basic
20 hours
XX
AC Theory III
20 hours
XXX
AC Theory II
10 hours
XXXX
AC Theory I
10 hours
DC Theory II
20 hours
X
XXXX
DC Theory I
20 hours
Courses
Maintenance Electrician
80 hours
Journey Worker
Specialty Electrician
120 hours
Journey Worker
Industrial Electrician
200 hours
Journey Worker Electrician
240 hours
ELECTRICAL ACADEMIC COURSEWORK
(CONTINUED ON PAGE 6)
-5-
FILING DEADLINE
AND EXAM
INFORMATION
The Board reviews applications and determines whether applicants meet the experience requirements. A
complete application along with appropriate fees must be received at least seven (7) working days before the
board meeting date. Board meetings are usually scheduled in the months of February, April, June, August,
October and December. Visit our website at cca.hawaii.gov/pvl for Board meeting schedule.
Examinations are usually scheduled in the month after the board meeting. Visit our website at cca.hawaii.gov/pvl
for exam schedule.
INSTRUCTIONS FOR FILING
APPLICATION
FORM
Complete the on-line fillable application and print the form OR print legibly in dark ink. Answer all questions. If
an item is not applicable, indicate "NA". Application must be signed. Submit application, supporting documents,
and application fee by the filing deadline.
SOCIAL SECURITY
NUMBER
Your Social Security Number is used to verify your identity for licensing purposes and for compliance with the
below laws. For a license to be issued you must provide your Social Security Number or your application
will be deemed deficient and will not be processed further.
The following laws require that you furnish your Social Security Number to our agency:
FEDERAL LAWS:
42 U.S.C.A. §666(a)(13) requires the Social Security Number of any applicant for a professional license or
occupational license be recorded on the application for license; and if you are a licensed health care practitioner,
45 C.F.R., Part 61, Subpart B, §61.7 requires the Social Security Number as part of the mandatory reporting we
must do to the Healthcare Integrity and Protection Data Bank (HIPDB), of any final adverse licensing action against
a licensed health care practitioner.
HAWAII REVISED STATUTES ("HRS"):
§576D-13(j), HRS requires the Social Security Number of any applicant for a professional license or occupational
license be recorded on the application for license; and
§436B-10(4), HRS which states that an applicant for license shall provide the applicant's Social Security Number if
the licensing authority is authorized by federal law to require the disclosure (and by the federal cites shown above,
we are authorized to require the Social Security Number).
FEES Attach the application fee of $40 (non-refundable). Additional fees will be assessed after board approval and
passage of the examination. Make checks payable to: COMMERCE & CONSUMER AFFAIRS. (check must be in U.S.
dollars and be from a U.S. financial institution.)
SUPPORTING
DOCUMENTS
Complete and ATTACH to your application:
1. Experience Verification Form MUST BE Completed & Signed by a licensed electrician or plumber! If
supervisor is licensed out-of-state, attach a verification of licensure that shall include the effective date
of the license. This form is used to verify the work experience of the applicant. The applicant completes the
top portion of the form and the licensed electrician/plumber verifies the work experience of the applicant by
describing in detail the work performed and by indicating the total work hours per work process (see page 2 of
the form for description of the work process), and the total hours of experience based on the total years of
service. The licensed electrician/plumber provides his licensing information and signs before a notary public.
If the state in which you gained your experience does not require licensure as a journey worker, supervising,
or master electrician or plumber and only requires a contractor's license, the Board will accept a notarized
Experience Verification form signed by the licensed contractor provided license verification as a contractor
is submitted which shall include the effective dates of licensure.
(CONTINUED ON PAGE 7)
-6-
2. License Verification Form(s) required if licensed in any other state or jurisdiction - This form is used to verify
any license held in other jurisdictions and whether any license has been encumbered or disciplined in any way.
The applicant must complete the top portion of the form, sign, and forward the form to the licensing jurisdiction
in which the applicant is licensed. Upon receipt of the completed form from the other jurisdiction, applicant
must submit this form with the application or have the licensing authority send the form directly to the Board.
Forms are required from each state or jurisdiction in which a license has ever been held.
3. Verification of completion of the required electrical academic coursework. The Board will accept copies of a
diploma, a certificate of completion, a certificate of competence, a certificate of achievement, a transcript with
a date of graduation or date degree conferred, or a letter from the registrar of a University of Hawaii Community
College indicating that all requirements have been met to complete the required electrical academic
coursework. The Board will also accept a certificate of completion of an approved apprenticeship program as
noted above.
SUPPORTING
DOCUMENTS
(cont'd)
Instructions for "YES" Answers to questions (3) thru (7) of the Application for License (EP-01)
The following documentation must be submitted with the license application. Applications for license will
not be considered without this material.
A.
Questions 5 and 6 refer to complaints, charges of unlicensed activity, or pending disciplinary actions for
any profession, occupation, or license. If your answer is "yes" to one or more of these questions, submit
the following:
1)
A statement signed by you explaining the circumstances; andi.
Copies of any documents from the agency, including final orders, petitions, complaints, finding of
facts and conclusions of law, and any other relevant documents;
ii.
If your application indicates criminal conviction, you must submit the following:2)
A statement signed by you explaining the circumstances leading to the conviction and detailing all
activities since the conviction, including employment and business involvements. Include job title,
period of employment, employer's name, description of duties, training attended, and educational
courses attended;
i.
A copy of the court order, verdict, indictment, judgment, guilty plea and terms of sentence; and ii.
If applicable, a copy of the terms of probation and/or parole and notarized statement from your
probation or parole officer as to your compliance with the court orders;
iii.
A current criminal history record check in your name, from the Hawaii Criminal Justice Data Center
(HCJDC), dated within 6 months. Contact the department of the Attorney General, Hawaii Criminal
Justice Data Center, Kekuanao'a Building 456 S. King Street, Rm. 101, Honolulu, HI 96813. Phone:
(808) 587-3100 or visit their website at: ecrim.ehawaii.gov to request a "Criminal History Record
Check".
iv.
If your criminal conviction occurred in a state or states other than Hawaii, a current criminal history
record check will be required from each state AND Hawaii. Contact the local authority or board in
each state for their forms, instructions and fees on obtaining criminal history record checks.
v.
Submit a copy or other state verification of a valid contractors or other appropriate license that
allowed you to contract to perform electrical or plumbing work. (If not currently valid, provide
verification that it was current and valid during the time period being claimed.)
•
NOTE: For those applicants who have had electrical or plumbing contractor licenses and who have been self
employed, you may self attest and personally complete the Experience Verification form provided you:
(CONTINUED ON PAGE 8)
-7-
ADDRESS The Board's mailing address is:
Board of Electricians & Plumbers
DCCA, PVL Licensing Branch
P.O. Box 3469
Honolulu, HI 96801
Phone No.: (808) 586-3000
Toll free voice access neighbor island numbers:
Kauai - 274-3141 ext. 6-3000
Maui - 984-2400 ext. 6-3000
Hawaii - 974-4000 ext. 6-3000
Molokai - 1-800-468-4644 ext. 6-3000
Lanai - 1-800-468-4644 ext. 6-3000
OR
If you wish to deliver your application in person or by overnight mail, the Board's street address is:
Board of Electricians & Plumbers
335 Merchant Street, Rm. 301
Honolulu, HI 96813
EXAMINATION Upon approval by the board of your application, you will be sent an "Examination Registration Form." This form
is to be completed and sent directly to the testing contractor along with the appropriate examination fee and
one (1) copy of your approval letter. Questions regarding the examination and study material should be directed
to Prometric fka Thomson Prometric.
Prometric
354 Uluniu St., Suite 308
Kailua, HI 96734
Phone: (808) 261-8182.
OR visit their website at: www.prometric.com/hawaii
NOTE: All electrician examinations will be "open code book" beginning in January 1998, and Prometric will
provide the appropriate electrical code book at the examination.
REQUEST TO TAKE THE LICENSING EXAMINATION OUT-OF-STATE - Must be approved by the Board. Submit
your written request along with your application in advance of the deadline date, to allow for sufficient processing
time. Please be advised that you are responsible for any additional cost for this out-of-state testing
accommodation and test locations are limited to sites at which the testing service has a secured office.
EXAMINATION
MATERIAL AND
CODE BOOK
The Electricians exam is based on the National Electrical Code (NEC), and the Plumbers exam is based on the
Uniform Plumbing Code (UPC). These may be purchased from the City and County Purchasing Division, City Hall,
Ground Floor, Honolulu, Hawaii (Phone: 523-4780).
LAWS AND RULES A copy of the laws, Chapter 448E, Hawaii Revised Statutes and rules Chapter 80, Hawaii Administrative Rules
relating to electricians and plumbers may be obtained by submitting a written request to: DCCA, P.O. Box 3469,
335 Merchant Street, Rm. 301, Honolulu, HI 96801. Chapter 436B, Hawaii Revised Statutes, the Professional and
Vocational Licensing Act should be read in conjunction with the above statutes.
•
The laws and rules are also posted on our website at: cca.hawaii.gov/pvl. Click on "Electricians &
Plumbers" and then select "Statute/Rule Chapter" in the box on the right.
ABANDONMENT OF
APPLICATION
Pursuant to HRS §436B-9 your application shall be considered abandoned and shall be destroyed if you fail to
provide evidence of continued efforts to complete the licensing process for two consecutive years. The failure
to provide evidence of continued efforts includes but is not limited to: (1) failure to submit the required
information and documents requested by the licensing authority within two consecutive years from the last date
the documents or other information were requested, or (2) failure to complete any additional requirements
for licensure that remain after approval of your application, such as attempting to complete an exam requirement,
within two consecutive years from the date your application was approved or (3) failure to provide the licensing
authority with any written communication during two consecutive years indicating that you are attempting to
complete the licensing process. If an application is deemed abandoned the applicant shall be required to reapply
for licensure and comply with the licensing requirements in effect at the time of the reapplication.
LICENSE FEES
UPON PASSING THE EXAMINATIONS, the following license fees will be due. (Do not send license fees with your
initial application).
PLUMBERS If applying for your license between July 1, and June 30, of the first year of
the triennium (2015, 2018, 2021, 2024) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $306
If applying for your license between July 1, and June 30, of the second year of
the triennium (2016, 2019, 2022, 2025) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $204
If applying for your license between July 1, and June 30, of the third year of
the triennium (2017, 2020, 2023, 2026) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $102
(CONTINUED ON PAGE 9)
-8-
If applying for your license between July 1, and June 30, of the first year of
the triennium (2014, 2017, 2020, 2023) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $306
If applying for your license between July 1, and June 30, of the second year of
the triennium (2015, 2018, 2021, 2024) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $204
ELECTRICIANS
If applying for your license between July 1, and June 30, of the third year of
the triennium (2013, 2016, 2019, 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $102
NOTE: One of the numerous legal requirements that you must meet in order for your new license to be issued is the
payment of fees as set forth in this application. You may be sent a license certificate before the payment you sent us
for your required fees is honored by your bank. If your payment is dishonored, you will have failed to pay the required
licensing fee and your license will not be valid, and you may not do business under that license. Also, a $25.00 service
charge shall be assessed for payments that are dishonored for any reason.
If for any reason you are denied the license you are applying for, you may be entitled to a hearing as provided by Title 16,
Chapter 201, Hawaii Administrative Rules, and/or Chapter 91, Hawaii Revised Statutes. Your written request for a
hearing must be directed to the agency that denied your application, and must be made within 60 days of notification
that your application for a license has been denied.
MAINTAINING THE LICENSE
RENEWAL AND
CONTINUED
COMPETENCY
REQUIREMENT
All PLUMBER licenses, regardless of issuance date, are subject to renewal on or before June 30, every three years
(triennial renewal) beginning June 30, 2006. *All licensed plumbers will need to provide proof of
completing the continued competency requirement at the time of renewal. Please keep the board informed
of any address changes in writing.
All ELECTRICIAN licenses, regardless of issuance date, are subject to renewal on or before June 30, every three
years (triennial renewal) beginning June 1996. All licensed electricians, except maintenance electricians,
will need to provide proof of completing the continued competency requirement at the time of renewal.
Please keep the board informed of any address changes in writing.
The continued competency requirement for all licensed plumbers and electricians except the maintenance
electricians is to:
1) Furnish proof of attendance at an educational course on the updates to the Uniformed Plumbing Code (UPC)
for plumbers which is updated every three years (2018, 2021, 2024, etc) and the National Electrical Code
(NEC) which is updated every three years (2017, 2020, 2023, etc). The Honolulu Community College (HCC)
has been approved to develop and teach these courses. Contact the HCC or participating community
colleges directly to schedule the either course.
OAHU
Roy Inouye
844-2326
HAWAII
Wilt Watanabe
974-7531
MAUI
Dawn Okazaki
984-3231
KAUAI
Bill Blackburn
245-8319
OR
2) Successfully complete an examination prescribed by the board on current updates to the UPC or NEC.
Prometric has been approved to develop and administer the examinations. The examination for electricians
will be "open book" and Prometric will provide the appropriate code book at the examination. Contact
Prometric at the following address or telephone number:
Prometric
354 Uluniu St., Suite 308
Kailua, HI 96734
ONE TIME
CONTINUED
COMPETENCY
EXEMPTION
A plumber or electrician licensee who has been issued a new license within one year of the renewal date shall
not be required to take the course or the examination to renew the licensee's license for the first renewal
period. This licensee shall, however, meet the continued competency requirements for subsequent renewals.
Phone: (808) 261-8182
-9-
RELEASE OF
INFORMATION
If an agency or individual is assisting you with the licensure process, we will not be able to release any information
to them unless you provide us with authorization. If you wish to do so, please complete the portion on "Release
of Information to Third Party", sign, and date it.
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.
RENEWAL AND
CONTINUED
COMPETENCY
REQUIREMENT
(cont'd)
Print Form
APPLICATION FOR EXAM AND LICENSE - ELECTRICIANS AND PLUMBERS
FOR OFFICE USE
Eff. Date:Lic. No.:
Please read the instructions before completing this form.
Check the TYPE OF LICENSE you are applying for (only one):
EJ ES EJS ESS PMEJI ESI EM PJ
LEGAL NAME (First, Middle) (Last)
Residence Address (Include Apt. No., City, State and Zip Code)
Mailing Address (ONLY if different from above) Social Security No.
Phone No. (Days) Other Names Used
EXPERIENCE IN THE TRADE
(If more space is needed,
use separate 8 1/2" x 11" sheets)
Dates (mo/yr)
From To
Hours a
week
Description of Duties and Position Title Name, Address and Phone No. of Employer
Check answers. If response to questions 5, 6, or 7 is "yes", refer to instructions for additional documents that must be submitted with
this application.
Are you at least 18 years of age? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Are you a U.S. citizen, a U.S. national, or an alien authorized to work in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Have you ever filed an application with Hawaii? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Do you presently hold or have you ever held an electrician's or plumber's license in Hawaii
or any other state or jurisdiction?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
1.
2.
3.
4a.
4b. If "yes", list all licenses you currently hold or have held. Indicate name of state or jurisdiction.
Expiration date: License No.:
Type of License: Effective Date:
5. Has any license ever been suspended, revoked or denied, or otherwise subject to disciplinary action? . . . . . . . . . . . . . . . . .
Yes No
EP-01 0417R
(CONTINUED ON PAGE 2 - SIGNATURE REQUIRED ON PAGE 2)
Are there any disciplinary actions pending against you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.
Yes No
7. Have you ever been convicted of a crime in any jurisdiction that has not been annulled or expunged? . . . . . . . . . . . . . . . . .
Yes No
Appl. . . . . . . . . . . . . . . . . . . . . . . . . . 193. . . . . . . . . . . . . . . . $40
Lic. . . . . . . . . . . . . . . . . . . . . . . . . . . . 195. . . . . . . . . . . . . . . . $52
CRF. . . . . . . . . . . . . . . . . . . . . . . . . . . 196. . . . . . . . . . . . . . . . $50/$100/$150
Ren. . . . . . . . . . . . . . . . . . . . . . . . . . . 190. . . . . . . . . . . . . . . . $52/$104
Service Charge. . . . . . . . . . . . . . . . BCF. . . . . . . . . . . . . . . . $25
AFFIDAVIT OF APPLICANT:
I certify that the statements, answers, and representations made in this application and in the documents attached are true and
correct. I understand that any misrepresentation is grounds for refusal to grant or subsequent revocation of license (Section 710-1017,
Sections 436B-19, and 448 E-10, Hawaii Revised Statutes). I further certify that I have read and will abide by the provisions of Chapter 448E,
HRS and Chapter 80, HAR.
Print Name of Applicant: Date:
Signature of Applicant Date
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.
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Release of Information to Third Party:
To assist me in the licensing process, I hereby authorize DCCA's staff to release any and all information regarding my application
(including, but not limited to application status) to the following third party:
Signature of Applicant Date
Print name of Individual who is assisting you:
Name of Organization:
Print Form
