Tdlr Form Oo4acr - Air Conditioning & Refrigeration Contractor Template
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4T
D
L
R
EXAS
EPARTMENT OF
ICENSING AND
EGULATION
P.O. Box 12157 - Austin, Texas 78711-2157
1-800-803-9202 - (512) 463-6599 - FAX (512) 475-2871
- CS.Air.Conditioning@license.state.tx.us
A
F
:
PPLICATION
OR
AIR CONDITIONING & REFRIGERATION CONTRACTOR
PURSUANT TO OCCUPATIONS CODE, CHAPTER 1302, TITLE 8
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RITE IN THE
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MMEDIATELY
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PMT.
MONEY
RECEIPT NUMBER
AMOUNT
TYPE
DO NOT WRITE ABOVE THIS LINE
DO
NONOTE: A
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NFORMATION
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YPED OR
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IF ALL REQUIREMENTS FOR A LICENSE ARE NOT MET WITHIN TWELVE (12) MONTHS OF THE FILING DATE, THE APPLICATION WILL BE CLOSED.
1. Applicant’s Full Name:
_______________________________________
_________________________
___________
___________
Last
First
Middle Initial
Suffix (JR, SR, III)
2. Date of Birth: ____________ - _________ - ____________
3. Gender
Female
Male
4. Applicant’s Social Security No.:
____ ____ ____ - ____ ____ - ____ ____ ____ ____
Note: Section 231.302 of the Texas Family Code REQUIRES all applicants to disclose their Social Security Number (SSN) when filing an application.
The SSN that is provided is confidential and is required to enforce Child Support orders. Failure to provide the SSN will prevent a license from being
issued and could ultimately lead to termination of the application.
5. Business Information
:
Federal ID Number
________________________________________
(Information regarding the Federal/Employer ID # may be obtained through this web page: )
____________________________________________________________________________________________________
Business Name(s)
_____________________________________________________________________________________
Physical location
(Business Address) Number, Street, Suite No., Apt. No.
______________________________________________________
(________) ___________________________
City
State
Zip Code
Area Code
Phone Number
Mailing address
__________________________________________________________________________________________________
Number, Street, Suite No., Apt. No.
(P.O. Box is allowed for this address.)
______________________________________________________
(________) ___________________________
City
State
Zip Code
Area Code
FAX Phone Number
6. Applicant’s Mailing Address :
(USED FOR ALL CORRESPONDENCE) (P.O. Box is allowed for this address.)
_____________________________________________________________________________________________________
Number, Street, Suite No., Apt. No. or P.O. Box
_______________________________________________________
(________) ___________________________________________
City
State
Zip Code
Area Code
Phone Number
FAX Number: (________)
________________________________
______________________________________________________
Area Code
Phone Number
E-mail Address ( for example) See Note 1
7. Have you ever been convicted of a criminal offense?
Yes
No
(Include all felonies and misdemeanors other than minor traffic violations.)
If YES, attach a “Criminal History Questionnaire” to this application.
All forms may be found at /ac/acrforms.htm.
THIS FORM CONSISTS OF 4 PAGES.
This
TDLR Form OO4ACR (Revised 10/2010)
This document is available on the TDLR website at .
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