Form Cc-008 - Certificate Of Competency Application Page 20
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26CERTIFICATE OF COMPETENCY APPLICATION
Form D
Section 8 - Qualifiers Responsibility Affidavit Form (Optional)
I hereby certify that _____________________________________________________is the qualifying agent for
(Qualifier’s legal name, ex: John Smith)
________________________________________________________________________________________________
(company’s full legal name INC/CORP/LLC - include d/b/a if applicable)
Located at_______________________________________________________________________________________
(Address)
City__________________________________________________State____________________Zip______________
and, that he/she has the authority to act for the firm or corporation in all matters connected with our contracting
business. To take the qualifying examination, to qualify the company and will supervise the construction or
installation contracted for, under the Certificate of Competency issued.
I further certify that I will immediately notify The Construction Industry Licensing Board of Palm Beach
County, if the above named qualifying agent shall sever connections with the firm or is no longer actively
supervising the construction or installation of work under contract. As outlined in Section 2(O) and 6 (C) of the
Special Act, Laws of Florida as amended.
_________________________________________________________________________________________________
Signature of Corporate Officer (if other than the applicant who is qualifying the corporation)
Date
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)
Form CC-08-10
Qualifiers Responsibility Affidavit
Rev. 12/9/16
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