Lineman Registration Form

    Today's Date:

    Home Local Number:

    State:

    Best Contact Number:

    Last Name (required)

    First Name (required)

    Middle Initial

    Address:

    City:

    State:

    Zip Code:

    CDL License:

    YesNo

    Current Medical Certificate:

    YesNo

    Clean Driving Record:

    YesNo

    Worker Classification:

    Journeyman LinemanEquipment OperatorGroundmanApprenticeForemanAdminAssessorOther

    Will you travel for storm work:

    YesNoSplicingAssessmentPole SettingPrimary

    Ability to climb poles:

    YesNo

    Are you available for long durations:

    YesNoSecondaryUndergroundSubstationTransmission

    Current Safety Certifications: (Check all that apply)

    Pole Top RescueCPRBucket RescueHazardous CommunicationChain Saw SafetyBlood Borne PathogenPersonal Protective Eq.First AidConfined Space1919.269 Elect. Hazard AwarenessMUTCD Traffic ControlUse of Insulated Tools