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2. Name of Firm:*
4. Street Number:*
6. Street Name:*
8. City:*
10. State:*
12. Zip:*
14. Phone:*
16. Fax:
18. Cell:
20. Pager:
22. Email:
24. Contact Name:*
26. Type of Business:*
    -- Select One --BlankElectricalGeneralLandscapePlumberRoofer
28. Business Owner's Name:*
30. Insurance Agent:*
32. Insurance Agent Phone:*
34. Upload Certificate of Insurance:
36. Upload License:
38. By Clicking “I agree,” you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your “electronic signature” is valid and binding upon you to the same force and effect as a handwritten signature.*

    1. I Agree
40. FOR VILLAGE USE ONLY
42. License No:
44. Expiration Date:
46. Date Issued:
48. Fee Received:
50. Approved By:
52. NO LICENSE SHALL BECOME EFFECTIVE UNTIL SUCH DATE AS THE REQUIRED CERTIFICATE OF INSURANCE HAS BEEN SUBMITTED AND IS ON FILE WITH THE VILLAGE. THE FEE IS $125.00 PER YEAR.
Leave This Blank:


53. Print Only

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