Form Cc-008 - Certificate Of Competency Application Page 9
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26CERTIFICATE OF COMPETENCY APPLICATION
Section 10 - Declaration of Written Affirmation
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required under the provisions of Chapter 67-
1876 Special Act, Laws of Florida, as amended, defining, regulating and governing contractors within the
County of Palm Beach, Florida; I hereby apply for a certificate of competency to qualify as a contractor in
Palm Beach County, Florida.
The undersigned hereby makes application for certification under the provisions of the Palm Beach County
Certification Law, Chapter 67-1876, Special Act, Laws of Florida, as amended, and vouches for the truth
and accuracy of all statements and answers herein.
I understand that my signature on this written declaration has the same legal effect as an oath or affirmation.
Under penalties of perjury, I declare that I have read the foregoing application and the facts stated in it are
true. I understand that falsification of any material information on this application may result in
disqualification or administrative action, including denial, a fine, suspension or revocation of the
license.
______________________________________________________________
Signature
Date
______________________________________________
Print Name
Page 8 of 8
Form CC-008
Certificate of Competency Application
Rev. 12/9/16
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