Electrical Work Liability Waiver Form

Client Full Name

First NameMiddle NameLast Name

Project/Property Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Electrical Work Site (if different)

Type of Electrical Work Requested

Brief Description of Work

Understanding of Potential Hazards

I confirm I am authorized to approve electrical work at this property

Signature of client or authorized representative