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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 #*

29. Contractor License #*

31. Type of Contractor *

33. Attach Copies of:*

    State of Florida License (DBPR) Card Proof of Workers Comp Insurance (w/ City of Temple Terrace as Certificate Holder)

35. 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.

    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.

37. Signature of Applicant:*

38. Date:*
    Date:

40. 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:


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

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field