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State Cert #:

State Reg #:

Cert of Comp #:

County BTR #:

City BTR #:

Other Lic #:

Company Name (DBA): Company Address: City: Mailing Address: City: Phone #: Type of Contractor: Qualifier’s Name: Qualifier’s Address: City:

State:

Zip Code:

State:

Zip Code:

CONTRACTOR’S REGISTRATION FORM

Fax #:

Email:

Driver License #:

State:

Zip Code:

Insurance Co. Name: Policy #: Effective Date:

LIABILITY INSURANCE Phone #:

Insurance Limits: Expiration Date:

Insurance Co. Name: Policy #: Effective Date:

WORKER’S COMPENSATION Phone #:

Insurance Limits: Expiration Date:

__________________________________________ Signature of Qualifier

__________________________________________ Date

__________________________________________ NOTARY as to Qualifier

__________________________________________ Date

__________________________________________ Printed name of NOTARY

__________________________________________ Seal

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