Profession 304 - Crane Operator License - Written Exam Application

Fee*: _______________ Exam Date*: ______________________

* For manual entry, the applicable fee and exam date can be found on

(www.continentaltesting.net).

Name: _________________________________________ Address: _______________________________________

City: __________________ State: _____ Zip: ______ Driver’s License #: _______________________________

Email: _________________________________________ Phone: _______________ Date of Birth: ____________

Present Occupation: _____________________________ Social Security Number: __________________________

Employer’s Name: ______________________________ Employer’s Name: ______________________________

Address: _______________________________________ Address: _______________________________________

City: __________________ State: _____ Zip: ______ City: __________________ State: _____ Zip: ______

Period of Employment From: _________ To: _______ Period of Employment From: _________ To: _______

Equipment Type: Crane ___ Derrick (stiffleg or guy) ___ Equipment Type: Crane ___ Derrick (stiffleg or guy) ___

Describe: _______________________________________ Describe: _______________________________________

Length of Boom: _____________________________ Length of Boom: _____________________________

Hrs. worked as Apprentice Crane Operator(oiler): ____ Hrs. worked as Apprentice Crane Operator(oiler): ____

Select the license classification for which you are applying:

Tower Crane Mobile Crane Drum Hoist

Have you ever held an Apprentice Crane Operator certificate? YES _____ NO _______

If YES, what was the time period? From: _____________________ To: ____________________________

Have you ever taken the City of Chicago’s Crane Operator License Exam? YES ______ NO _______

If YES, when did you most recently take the exam? Date: _____________________________________________

______________________________

Subscribed and sworn to before me

Applicant's Name this _______ day of ______ Year ____

______________________________ _______________________________

Applicant's Signature Notary Signature

(Seal)

This box is reserved for City use.

____________________________

(Approval – Board Member)

Mail Forms To: City of Chicago Trade Licenses & Examinations

P.O. BOX 388249

Chicago, IL 60638-8249 CTS -2014