Plumbing Contractors Registration Form - City Of Walker

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CITY OF WALKER
4243 Remembrance Rd., N.W.
Walker, Michigan 49544
PLUMBING CONTRACTORS REGISTRATION FORM
BUSINESS NAME ________________________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________
_________________________________________________________________________________________
CITY
STATE
ZIP CODE
BUSINESS PHONE___________________________FAX NO______________________________________
PERSON
LICENSED_____________________________________DOB_______________________________________
PERSONS AUTHORIZED ___________________________ _______________________________________
TO PULL PERMITS
UNDER LICENSE
___________________________ _______________________________________
ALL LICENSED CONTRACTORS COMPLETE THIS SECTION
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)
$10.00 FEE TO ACCOMPANY THIS REGISTRATION
___________________________
_________________________________
RECEIPT #
DATE COMPLETED OR RECEIVED
___________________________
__________________________________
REGISTRATION #
DATE ISSUED

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