Home Improvement Contractor Registration

Home Improvement Contractor Registration
TO BEGIN THE APPLICATION YOU WILL NEED THE FOLLOWING:

1.) Proof of insurance

C105.2- Workers compensation (ACCORD FORMS NOT ACCEPTED)

DB120.1- Disability (ACCORD FORMS NOT ACCEPTED)

or CE-200 Exemption (ACCORD FORMS NOT ACCEPTED)

2.) Electronic copy of owners Photo ID
Business Type:*

IndividualPartnershipDomestic CorporationForeign Corporation
Business Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number:*

Area CodePhone Number
Cell Phone Number:*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email*
example@example.com
Type of Business
Years in Business
Approximate Number of Employees
OWNER INFORMATION
Owner Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
ADDITIONAL OWNERS, PARTNERS OR OFFICERS
Do you have any additional Owners/Partners or Officers of your company

YesNo
Name of partner/Officer

First NameLast Name
Date of Birth of Partner/Officer

MonthDayYear
Date
Address of Partner/Officer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Partner/Officer

Area CodePhone Number
Cell Number of Partner/Officer

Area CodePhone Number
Fax Number of Partner/Officer

Area CodePhone Number
Email of Partner/Officer
example@example.com
Do you have another Partner/ Officer or Owner to list

YesNo
Name of Partner/Officer

First NameLast Name
Date of Birth of Partner/Officer

MonthDayYear
Date
Address of Partner/Officer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Partner/Officer

Area CodePhone Number
Cell Number of Partner/Officer

Area CodePhone Number
Fax Number of Partner/Officer

Area CodePhone Number
Email or of Partner/Officer
example@example.com
Signature*

Clear
Should be Empty:

Home Improvement Contractor Registration

OWNER INFORMATION

ADDITIONAL OWNERS, PARTNERS OR OFFICERS