Form Cc-008 - Certificate Of Competency Application Page 19
Download a blank fillable Form Cc-008 - Certificate Of Competency Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cc-008 - Certificate Of Competency Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26CERTIFICATE OF COMPETENCY APPLICATION
Rev. 12/9/16
Form C
Section 7- Affidavit of Construction Experience Form
Construction Industry Licensing Board of Palm Beach County
nd
2300 N. Jog Road, 2
Floor Ste. 2W-61, West Palm Beach, FL 33411
Instructions:
This form is to be filled out in black or blue ink by the contractor under whom work was performed and returned to the address above.
The Contractor’s License and Driver’s License must be included.
Alterations of any kind will void this form.
Affidavit Forms must be furnished to substantiate the minimum experience requirement in the category for which application is made.
Name of Applicant:
Name of qualifier where applicant is still employed or was formerly employed:
Company Name:
Business Address:
Business Phone:
Cell Phone:
Email:
Time Employed From: (mm/yyyy)
To: (mm/yyyy)
During the dates indicated above, our company records specify the above named employee performed in the capacity of:
Description of job duties performed while employed:
Total Time Employed with company:
Total Time in a Supervisory Capacity with company:
_____________________(yy/mm)
_______________________(yy/mm)
I attest that I am the qualifier for the above construction company and hold or have held a Certificate of Competency and/or
License #_________________________
Issued By__________________________________________As a____________________________________Contractor.
________________________________________
_________________________________________________
(Print Qualifying Agents Name)
(Signature of Qualifying Agent)
STATE OF
}_____________________________
COUNTY OF }_____________________________
Subscribed
and
sworn
to
(or
affirmed)
before
me
on
_________________
(date)
by________________________________________(name of affiant, respondent or other signer). He/she is personally
known to me or has presented________________________________ (type of identification) as identification.
____________________________________
(NOTARY'S SIGNATURE AND SEAL)
This form may be duplicated.
IF YOU ARE OR WERE SELF-EMPLOYED - verification of required experience may be supplied from copies of past and current certificates
of competency or license, or original notarized letters from Building Officials or Licensing Agencies, plus A and/or B A) copies of fully
executed contracts (such as invoices with supporting documents ex: 1099, tax returns, etc.) - one per month covering the required time period,
OR if possible, B) notarized letters from contractors you performed work for as a subcontractor (listing the time frame for each of the jobs and
description of work involved)
Please Note: All information reported in the above affidavit will be verified by our office.
Form CC- 08-09 Rev. 1/16
Affidavit of Construction Experience
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal