Contractor Registration Form
Date: ____________
Related Permit #, Job Site Address or Project Name (if applicable): ________________________________________________
Contractor
Name: _______________________________________________________
New
Update
Address: _____________________________________________________
City: ________________________ State: ____
Zip: ________________
Company Name: _______________________________________________
Primary Phone #: _______________
Alternate Phone #: _______________
Fax #: ______________
E-mail: _______________________________________________________
License/Insurance/ Business Tax Receipt /Bond Information*
Issued By
Type
License/Policy #
Expiration Date
_________
________________ _________________________ _____________
Contractor License
_________
________________ _________________________ _____________
Insurance
_________
_________________________ _____________
Business Tax Receipt
_________
________________
_____________________ _____________
Bond
Amt:
Contractor Company Name
Company Name: _______________________________________________
New
Update
Address: _____________________________________________________
City: ______________________
State: ____
Zip: ________________
Primary Phone #: _______________
Alternate Phone #: _______________
Fax #: ______________
E-mail: _______________________________________________________
Insurance/ Business Tax Receipt /Bond Information*
Issued By
Type
License/Policy #
Expiration Date
_________
________________ _________________________ _____________
Insurance
_________
_________________________ _____________
Business Tax Receipt
_________
________________
____________________
_____________
Bond
Amt:
Other (specify role) _________________________
Name: _______________________________________________________
New
Update
Address: _____________________________________________________
City: ______________________
State: ____
Zip: ____________
Company Name: _______________________________________________
Primary Phone #: _______________
Alternate Phone #: _______________
Fax #: ______________
E-mail: _______________________________________________________
Insurance/ Business Tax Receipt /Bond Information* (if applicable)*
Issued By
Type
License/Policy #
Expiration Date
_________
________________ _________________________ _____________
Insurance
_________
_________________________ _____________
Business Tax Receipt
_________
________________
____________________
_____________
Bond
Amt:
*Copies of current license(s), certification(s), certificate(s) of insurance, competency card and/or original contractor surety
bond (if applicable) must be provided or be on file with the Office of Permitting Services.
Rev 10/2007
ECONOMIC DEVELOPMENT DEPARTMENT
PERMITTING SERVICES DIVISION
CITY HALL 400 SOUTH ORANGE AVENUE FIRST FLOOR P.O. BOX 4990 ORLANDO, FLORIDA 32802-4990
PHONE 407.246.2271 FAX 407.246.3420
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