Change In Officers - Contractors License Form
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1Tennessee Board for Licensing Contractors
500 James Robertson Pkwy.
Mailing Address:
Nashville, TN 372431150
Telephone: 8005447693 or (615) 2535741
Fax: (615) 5322868
Website:
Email:
Contractors.HomeImprovement@TN.Gov
CHANGE IN OFFICERS – CONTRACTOR’S LICENSE
No Fee
Pursuant Rule 0680108, contractors must report any change in officers within 30 days. As long as there
has not been a majority change in ownership from a purchase of nonstockholders; merger; or reorganization
due to bankruptcy, you may notify the Board in writing or use this form prepared for your convenience.
(Note: Changes in ownership, merger or reorganization, requires completion of the “Contractor’s License
Application” for a new license to be issued, pursuant T.C.A. § 626111(2). The law and rules may be
reviewed from our website.) There is not a fee for reporting changes in officers.
LICENSE INFORMATION:
License ID# 000________
License Name:____________________________________________________
Address:_________________________________________________________
City, State and Zip:_________________________________________________
(__No Change; __Yes – New Address)
Telephone: (_____)______________; Fax: (____) ______________
Email:___________________________________________________________
OFFICER INFORMATION:
:
This is to report the following changes in officers
1. Name: ______________________________ Title: ____________________
SS#: __ __ __ __
(last 4 digits)
Ownership: ___No; ____Yes ________%
2. Name: ______________________________ Title: ____________________
SS#: __ __ __ __
(last 4 digits)
Ownership: ___No; ____Yes ________%
3. Name: ______________________________ Title: ____________________
SS#: __ __ __ __
(last 4 digits)
Ownership: ___No; ____Yes ________%
4. Name: ______________________________ Title: ____________________
SS#: __ __ __ __
(last 4 digits)
Ownership: ___No; ____Yes ________%
A. Represents a majority change of ownership by nonstockholders purchase? ___No ___*Yes
(*If yes, this would require a Contractor License Application to be completed for a new license, T.C.A. § 626
111(4)(e)(2); would need to contact the office for more information on obtaining another license.)
B. Has any officer been convicted of a felony?
___ No ___ Yes
Attach Explanation
C. Is any officer listed on another contractor’s license? ___ No ___ Yes
License ID#000_______
_____________________________
_______________ _____________
Signature of President/CEO
Title
Date
(Rev. 10/08)
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