City of Temple Terrace Customer Service

Contractor Registration Form

2. Application For Contractor Registration
4. Name of Business *
6. Mailing Address1*
8. Mailing Address2
10. City*
11. State*
12. Zip*
14. Business Phone #*
16. First Name of License Holder*
17. Last Name of License Holder*
19. Residence Address1*
21. Address2
23. City*
24. State*
25. Zip*
27. Phone #*
28. Applicant Email Address*
30. Contractor License #*
32. Type of Contractor *
34. Attach Copies of:*
    State of Florida License (DBPR) Card Proof of Workers Comp Insurance (w/ City of Temple Terrace as Certificate Holder) Proof of General Liability (w/ City of Temple Terrace as the Certificate Holder)
36. Signature of Applicant:
    Affidavit of applicant: I, the undersigned Individual; or if a corporation, for itself, its officers and directors, hereby swear or affirm that I am duly authorized to make the foregoing application and that all statements are a true and correct representation. Further, I acknowledge that I have read this application and agree that providing false information shall constitute grounds for revocation of any license pursuant hereto.
38. Signature of Applicant:*
39. Date:*
    Date:
41. Electronic Signature of Applicant*

    1. By checking this box, I acknowledge that I am electronically signing this form and that the information above is true and correct to the best of my knowledge.
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field