Out - Of - State License Verification Form - 2008
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1NEVADA STATE CONTRACTORS BOARD
9670 GATEWAY DRIVE, SUITE 100, RENO, NEVADA, 89521 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
OUT - OF - STATE LICENSE VERIFICATION FORM
THIS FORM MUST BE COMPLETED WHEN APPLYING FOR EXAM WAIVER BASED ON RECIPROCITY WITH
ARIZONA, CALIFORNIA, OR UTAH
INSTRUCTION TO APPLICANT
Applicant Name________________________________
Company Name________________________________
Insert your name and address and complete the top
portion of this request.
Give the form to the
Street Address_________________________________
appropriate agency. The verifying agency will mail the
City__________________________________________
completed verification to you at the address you have
listed.
Include the completed form with your
State
Zip _________________
application.
I am requesting licensure in the State of Nevada as a
.
I am/have been licensed in the State of
issued under the company name of
.
_______________________________________________. My Social Security # is
I authorize you to release, to the State of Nevada, all information pertaining to license number:
.
_______________________________________
___________________________________________
Print Name of Applicant
Signature of Applicant
NOTE TO APPLICANT: COMPLETE A SEPARATE FORM FOR EACH LICENSE NUMBER
TO VERIFYING STATE:
Please furnish the information requested. Sign and verify the document. Place the
completed form in an envelope, seal the envelope, and provide it to the applicant either in person or by mail.
Company Name ____________________________________________________________________________
Type of License (Classification) _________________________________________________________________
Original Date of Issue
License Number________________
Amount of Limit (If any)
Amount of Bond (If any)______________________
Any record of suspensions, revocations, other disciplinary actions, or current Complaints?_________ , If yes, please provide a copy of
the action.
Current Status of License: ________________
If not Active, Reason: ___________________________
Name of Qualifying Individual & Title ______________________________________________________________
Licensed by:
Waiver of Exam (Basis of Waiver): _____________________________________________
Successful Completion of Exam - Specify Type:_________________________________________
Endorsement from the State of: _________________________________________
Other Personnel Listed & Titles_________________________________________________________________
AGENCY SEAL
SIGNATURE
TITLE _________________________
Nevada State Contractors Board
New License Application
(Revised 10/2008)
Page 17 of 23
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