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