State Certified Contractor Registration Form Page 2

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BOARD OF COUNTY COMMISSIONERS
ESCAMBIA COUNTY, FLORIDA
Development Services Department
3363 West Park Place
Pensacola, FL 32505
(850) 595-3550 - Phone
(850) 595-3401 - FAX
Contractor Licensing Fax No.:
(850) 595-3401
STATE CERTIFIED REGISTRATION FORM
INFORMATION ON THIS SHEET SHOULD PERTAIN TO THE LICENSE HOLDER. THE
FOLLOWING ITEMS MUST BE PRESENTED FOR COMPUTER REGISTRATION:
1.
Contractor must provide copy of State license and all other required documentation.
2.
Contractor’s driver’s license for identification purposes.
3.
Certificate of Insurance for Workers’ Comp and General Liability Insurances.
4.
Include a $27 Registration Fee made payable to “Escambia County Building Inspections
Division.”
PLEASE PRINT CLEARLY OR TYPE
Contractor’s Full Legal Name
(no nickname) _______________________________________________________________________
Contractor’s Printed Name _____________________________________________________________
Date of Birth: ___________________
____________________________
Driver’s License # & State Issued:
Contractor’s Home Address ____________________________________________________________
City _________________________ State __________________ Zip Code _________________
Contractor’s Company Name____________________________________________________________
Business Address _____________________________________________________ Zip Code _______
Mailing Address _______________________________________________________Zip Code _______
Home Ph. _____________________ Business Ph.___________________ Fax No._________________
Cell No. _____________________________ Other Contract No. _______________________________
Email address _______________________________________________________________________
LICENSING & INVESTIGATONS SECTION
CONTRACTOR LICENSING

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