Passed State Exam

Passed State Exam
This form is to be completed by the following classifications only:

Inside Wireman Apprentice
Telecommunications Apprentice
Advanced Placement Apprentice

*Please allow two (2) to four (4) weeks for the Trust Office to process your $175 reimbursement check.*
Today's Date*

MonthDayYear
Date
Passed Date*

MonthDayYear
Date
Name*

First NameLast Name
Address. (This is where we will send your $175 reimbursement check.)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
Please enter the email address you would like your confirmation email sent to. example@example.com
How many attempts did it take you to pass the exam?*

1st Attempt2nd Attempt3rd Attempt4th Attempt5th Attempt
Please upload a copy of your PSI passed exam confirmation. (Make sure the image is clear and all wording is able to be read)*

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Signature*

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