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CONTRACTOR REGISTRATION FORM |
COMPANY NAME: ________________________________________________________
NAME OF CONTRACTOR: __________________________________________________
REGISTER FOR (TRADE): __________________________________________________
(General, Electrical, Mechanical, Plumbing, Etc.)
MAILING ADDRESS: ______________________________________________________
CITY/STATE: ___________________________________ ZIP: ______________
TELEPHONE NUMBER (WORK): _________________ (FAX):
(MOBILE): _______________ (E-MAIL): __________________
RESPONSIBLE PERSON: ______________________ TITLE: ______________________
IF APPLICABLE PLEASE PROVIDE LICENSE NUMBER:
OTHER LICENSES: _______________________________________________________
I hereby state that the above information is true and correct. I understand that this registration is a matter of public record and the information contained herein will be available to the public. I understand and agree that failure to provide requested information or providing false information in this registration form can result in denial, suspension or cancellation of registration. I further understand and agree that revocation, suspension or denial of my state or other applicable license will result in the automatic denial, suspension or revocation of this registration. I have read the city ordinance 6-7(d) and understand and agree to the causes for denial, suspension or revocation of this registration stated therein.
SIGNATURE: ___________________________________
PRINT NAME: __________________________________
DATE: ________________________________________
THE FEE FOR REGISTRATION IS $100.00.