Residential Contractors Registration Form - City Of Walker

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CITY OF WALKER
243 Remembrance Rd., N.W.
4
Walker, MI 49534
PHONE: (616) 791-6858
FAX: (616) 791-6881
RESIDENTIAL CONTRACTORS REGISTRATION FORM
BUSINESS NAME ______________________________________________________________________
BUSINESS ADDRESS __________________________________________________________________
_____________________________________________________________________________________
CITY
STATE
ZIP CODE
BUSINESS PHONE (
)_____________________________FAX (
)_____________________
CELL NUMBER (
) __________________________________________
PERSON LICENSED ____________________________________________________________________
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)
$15.00 FEE TO ACCOMPANY THIS REGISTRATION
____________________________________
___________________________________
RECEIPT #
DATE COMPLETED OR RECEIVED
_____________________________________
___________________________________
REGISTRATION #
DATE ISSUED

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