Mechanical Contractors Registration Form - City Of Walker

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CITY OF WALKER
4243 REMEMBRANCE RD NW
WALKER, MI 49534
PHONE# (616) 791-6214 FAX # (616) 791-6881
MECHANICAL CONTRACTORS REGISTRATION FORM
BUSINESS NAME__________________________________________________________________________
BUSINESS ADDRESS ______________________________________________________________________
__________________________________________________________________________________________
CITY
STATE
ZIP CODE
BUSINESS PHONE ______________________________ FAX #___________________________________
PERSON LICENSED _______________________________________________________________________
PERSONS AUTHORIZED _______________________________ _________________________________
TO PULL PERMIS
UNDER LICENSEE _____________________________________
________________________________
ALL LICENSED CONTRACTORS COMPLETE THIS SECTION
STATE LICENSE NUMBER ____________________ EXPIRATION DATE __________________________
CITY LICENSE (IF ANY) ______________________
A) NAME OF INSURANCE CARRIER PROVIDING WORKERS DISABILITY COMPENSATION
______________________________________________________________________________________
1) ATTACH CERTIFICATE OF INSURANCE OR
2) ATTACH EXPLANATION OF EXEMPTION
B) IRS EMPLOYER IDENTIFICATION NUMBER
_______________________________________________________________________________________
1) ATTACH EXPLANATION OF EXEMPTION IF YOU DO NOT HAVE THE ID NUMBER
C) MESC EMPLOYER NUMBER _________________________________________________________
1) ATTACH EXPLANATION OF EXEMPTION
SIGNATURE OF LICENSEE_______________________________________________________________
(ATTACH COPY OF LICENSE)
$15.00
ADMINISTRATIVE FEE TO ACCOMPANY THIS REGISTRATION
______________________________
_______________________________________
RECEIPT #
DATE COMPLETE OR RECEIVED
_______________________________
_______________________________________
REGISTRATION #
DATE ISSUED

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