Fillable A check, cashiers check, or money order in (Nevada State Contractors Board)

Fill Online, Printable, Fillable, Blank A check, cashiers check, or money order in (Nevada State Contractors Board) Form

Use Fill to complete blank online NEVADA STATE CONTRACTORS BOARD pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

A check, cashiers check, or money order in (Nevada State Contractors Board)

On average this form takes 81 minutes to complete

The A check, cashiers check, or money order in (Nevada State Contractors Board) form is 25 pages long and contains:

  • 1 signature
  • 47 check-boxes
  • 299 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Nevada State Contractors Board forms online.

BROWSE NEVADA STATE CONTRACTORS BOARD FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NEVADA STATE CONTRACTORS BOARD
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
www.nscb.nv.gov
Nevada State Contractors Board
New License Application
(Revised 12/2021)
BEFORE SUBMITTING YOUR APPLICATION,
PLEASE MAKE SURE YOU HAVE THE FOLLOWING:
A check, cashier’s check, or money order in the amount of $300 payable to
“Nevada State Contractors Board” or “NSCB”
ALL signatures requested within the application
Experience Documentation (see Section 7)
Resume detailing all current and past employment
Background Disclosure Statement and Fingerprint Background Waiver forms for
ALL persons listed on the application
Copies of driver’s licenses or government-issued IDs for all persons listed on the
application
Financial Statement (See Section 11)
Child Support Information Statement – Sole Proprietors ONLY
ARE YOU A MEMBER OF THE
MILITARY? MILITARY
SPOUSE? VETERAN?
The Nevada State Contractors Board
is here to help expedite the licensing
process. For more information, visit
www.nscb.nv.gov/vap.html
STILL HAVE QUESTIONS?
The Nevada State Contractors Board
welcomes you to attend its online
Business Assistance Program held
every 4
th
Friday of the month from
9:00 a.m. to 11:00 a.m. Find out
more about this program and
download additional resources at
www.nscb.nv.gov/bap.html
NSCB is not affiliated with and does not endorse or recommend any contractor licensing schools or services.
Applicants are responsible for all information contained within the application and should be cautious when
using a third party agency to complete the required information.
NEVADA STATE CONTRACTORS BOARD
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
www.nscb.nv.gov
Page 1 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
APPLICATION FOR CONTRACTOR’S LICENSE
Read all instructions carefully. The Board desires to provide courteous and timely service to all applicants. To maximize its
efficiency and the level of service, the Board will ONLY process complete applications that include all applicable
supporting documents and fees. The Board will not act as your agent in gathering information or supporting documents
necessary for the consideration of your license application.
Please type or print in ink when completing this form.
You will need to obtain a Nevada Business ID prior to completing this application. To do so, contact the Nevada Secretary of
State to complete the application for a Nevada State Business License. www.nvsilverflume.gov/startBusiness or (800) 450-8594
Include the nonrefundable application fee of $300.00 when submitting the completed application to the Board.
Leave no space blank. If a particular question or request for information does not apply to you, write “N/A” in the blank
space to indicate the question has received your attention.
SECTION 1 – BUSINESS NAME AND ADDRESS
Legal Business Name:
• The Legal Business Name must match the name provided to the Secretary of State’s office for your Nevada State Business
License.
• If the Board determines another licensee or applicant is using a similar business name, you will be requested to choose a
different name, which may require you to file additional paperwork. If unsure, check with the Board’s office first.
Fictitious Business Name (dba), if applicable: _ _
• A Fictitious Business Name is used only if you will be doing business as a name other than your legal business name.
• A filed copy of your fictitious name certificate must be included.
Nevada Business ID: NV
• Your Nevada Business ID begins with “NV” and can be found on your Nevada State Business License.
Business Entity Type:
Corporation Limited Liability Corporation (LLC) Limited Partnership *Sole Proprietor Joint Venture
• Please check the business entity type that was filed with the Nevada Secretary of State’s Office.
• *If a Sole Proprietor, please complete the Child Support Information Statement and have your spouse (if applicable)
complete a Background Disclosure Statement (Attachment A)
Physical Business Address:
(Street Address)
(City) (State) (Zip)
Mailing Address for Business: Same as Above
(Street Address or P.O. Box)
(City) (State) (Zip)
Phone No.: ( ) Official Company Email Address: _____
(The Board will use this email address to correspond with you regarding this
application and future licensing matters; cannot be a third party.)
At least one address must be a physical location, not a post office box or mail drop.
Page 2 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
SECTION 5 – ASSOCIATES
• Provide the name and address for your designated Registered Agent who must be physically located in Nevada who
can and is authorized to receive service of process on behalf of the applicant.
Name:
Address: , NV
(Street Address) (City) (Zip)
The License Classification determines the scope of work you will be allowed to perform as a licensed contractor. A list of all
classifications can be found on the Board’s website or by referencing Nevada Administrative Code 624.140-624.585.
I am applying for the following License Classification(s):
Please describe the type of work you intend to perform.
SECTION 4 – PRINCIPALS AND QUALIFIED INDIVIDUALS
Based on the business entity type, the information below needs to be completed for the following persons:
• Corporation: All elected officers
• Sole Proprietor: Individual applying (owner)
• General Partnership: All partners
• Limited Partnership: All general partners
• Limited Liability Company (LLC): All managers and members with managing authority
• Joint Ventures: All parties of the Joint Venture
PRINCIPALS
FIRST NAME
MIDDLE NAME
LAST NAME
TITLE
FIRST NAME
MIDDLE NAME
LAST NAME
TITLE
FIRST NAME
MIDDLE NAME
LAST NAME
TITLE
(ATTACH A SEPARATE SHEET IF NECESSARY)
BACKGROUND DISCLOSURE FORM
• Background Disclosures and Fingerprints: Each person listed above and your qualified individual(s) listed under Section 7
must complete the background disclosure statement and fingerprint waiver form included within the application.
Do any persons (other than those listed in Section 4) own 25% or more of: (a) The stock in the corporation; (b) Interest in the limited
liability company; or (c) Interest in the limited partnership?
No Yes NAME % OWNED
SECTION 3 – LICENSE CLASSIFICATION
Page 3 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
SECTION 6 – PAST OR CURRENT CONTRACTOR’S LICENSES
If you or anyone appearing on this application have EVER been listed on a contractor’s license in Nevada or ANY other state at any
time – past or current – please fill in the information below for all licenses obtained.
• Past licenses include ANY licenses that are revoked, suspended, withdrawn, inactive, cancelled, etc.
• Indicate N/A in the field below if you have not.
Company Name
State
License #
Issue Date
License Status
(ATTACH A SEPARATE SHEET IF NECESSARY)
SECTION 7 – QUALIFIED INDIVIDUALS
• The qualified individual or “qualifier” is the person who meets the experience qualifications and examination requirements
for the license. The qualified individual must be a bona fide member or employee of the licensee and perform the duties and
responsibilities set out in NRS 624.260.
• Separate qualifiers for individual subclassifications are not allowed.
• If the individual currently serves as a qualified individual on another license, proof of ownership may be required.
I certify under penalty of perjury that I will act in the capacity of the qualified employee for this licensee and perform the duties required
of me pursuant to Chapter 624 of the Nevada Revised Statues and Nevada Administrative Code, Chapter 624. If at any time I cease to be
employed by, or associated with this company, I will immediately provide written notification to the State Contractors’ Board. Please
photocopy this page if additional qualified employees should be included.
FIRST NAME
MIDDLE NAME
LAST NAME
I will be acting in the following capacity:
Management Qualifier (This individual must pass the construction management examination)
Trade Qualifier (This individual will meet the technical experience trade examination requirement)
Both Management and Trade Qualifier
(Signature) (Date)
FIRST NAME
MIDDLE NAME
LAST NAME
I will be acting in the following capacity (if Management & Trade Qualifier are separate individuals):
Management Qualifier (This individual must pass the construction management examination)
Trade Qualifier (This individual will meet the technical experience trade examination requirement)
Both Management and Trade Qualifier
(Signature) (Date)
WORK EXPERIENCE
• You must have, within the 15 years immediately preceding the filing of this application, a minimum of 4 years work
experience as a journeyman, foreman, supervision employee or contractor in the specific classification requested. Work
experience documentation must be provided with the application.
o
DOCUMENTED WORK EXPERIENCE: The Board will accept the following types of documentation in support of your
experience.
1. Four (4) Certification of Work Experience Forms (Certificates) for EACH Trade Qualifier (Attachment B);
Certificates should be completed by employers, other than the applying company. If you are a self-employed
contractor, customers for whom you have performed work for should complete them. Relatives cannot
complete the certificates, unless they were your employer.
Page 4 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
Each certificate must verify the experience for the trade(s) being applied for. Certificates that are not complete or
specific regarding the actual work performed will not be accepted.
PLEASE NOTE: The aggregate time of experience (all certificates combined) must equal a minimum of 4 full
years (1460 days). Each individual certificate does not have to demonstrate 4 years’ experience.
Any certificate determined to be false or misleading may be considered misrepresentation or omission of a
material fact, in violation of NRS 624.3013(2).
Additional documentation may be requested by the Board as necessary.
2. A current Master’s Certification issued by a governmental agency or its officially recognized agent in a discipline
substantially similar to the requested classification;
3. Proof of transferrable military experience and training; or
4. Proof of eligibility for Licensure by Endorsement (See Section 9).
• RESUME OF EXPERIENCE: Complete the Resume of Experience (Attachment C)
WHEN DOCUMENTATION OF WORK EXPERIENCE & RESUME ARE NOT REQUIRED:
•
If the qualifier has served as a qualified employee in the same classification on another Nevada state contractor’s license
within the last 10 years and your documentation is still on file with the NSCB.
• Examination Requirements: A Business and Law (CMS) and trade examination will be required. The trade exam will be specific
to the classification requested. You will receive an Examination Eligibility form after the application is submitted and experience is
verified. Candidate information bulletin, exam content outlines, and order forms for the “CMS” exam and trade
exam(s) reference
manuals are available on the Board’s website.
• Examination fees are separate and will be paid directly to the Board’s exam provider.
• You May Be Eligible for Waiver of the trade exam under the following conditions:
o
Current/Recent Nevada Qualified Employee: If you have served as a qualified employee on a license in the State of
Nevada in the same classification requested in good standing within the last 10 years and your test scores are still on file
with the NSCB.
o
B or B-2 Exam Waiver: Applicants for a full “B” General Building or “B-2” Residential and Small Commercial license may
be considered for waiver of the trade exam if you have passed the National Association of State Contractor Licensing
Agencies (NASCLA) Accredited General Building Exam. You will need to purchase and electronically send your
transcript to the Board. Work experience documentation, as outlined in Section 7, must be provided.
o
Trade Exam Waiver by Endorsement – You may qualify for waiver of the trade exam by endorsement if you are
licensed in one of the states listed on the State Equivalency Chart, available online.
SECTION 9 – LICENSURE BY ENDORSEMENT
• Under certain circumstances the Nevada State Contractors Board will waive the trade examination requirement and/or the
experience certification requirement for applicants that qualify for licensure by endorsement. These waivers are granted for
applicants who are licensed in states determined by Nevada to have substantially equivalent requirements.
• In order to apply for licensure by endorsement, you will need to have been actively licensed in the endorsing state for the past
four (4) years, passed the equivalent exam, and not have had any disciplinary actions, suspension, revocation or other
sanctions against your license.
• Please review the State Equivalency Chart to determine if you are eligible to be relieved of the trade examination and/or
experience certification requirement based on endorsement by another state.
• In order to be considered for licensure by endorsement you must submit with your application a Request for Verification of
License, completed by your endorsing state. (Attachment D).
I am requesting licensure by endorsement based on the license listed below and have attached a completed Request
for Verification of Licensure form from the endorsing state.
COMPANY NAME
LICENSE #
STATE
**The Board reserves the right to require an examination, and/or experience certifications of any applicant
SECTION 8 – EXAMINATION REQUIREMENTS
Page 5 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
r
egardless of current or previous licensure.**
SECTION 10 – MONETARY LIMIT
• The Monetary Limit is the maximum contract a licensed contractor may undertake on one or more construction contracts on a
single construction site or subdivision site for a single client. It is determined by consideration of the factors set forth in NRS
624.260, 624.262, 624.263, and 624.265. Please note: Staff references these statutes to assess your financial responsibility with
regard to the monetary limit you are requesting.
State the specific Monetary Limit desired (value ranges are not acceptable): $_______________________
The financial statement requirements for your requested limit are listed below and must be included with your application.
SECTION 11 – REQUIRED FINANCIAL DOCUMENTS
NOTE: A financial statement IS REQUIRED regardless of the size/amount of the monetary limit.
1.
FINANCIAL STATEMENT REQUIREMENTS: Your financial statement will need to be prepared based on the Monetary Limit you
are requesting. It is important that you read through the specific requirements below, and seek the assistance of a Certified Public
Accountant (CPA) when necessary. All financial statements must meet the following criteria:
o
Financial statements must be for the applying entity. Sole proprietors and each general partner of a general
partnership must submit personal statements.
o
All statements must be in U.S. dollars.
o
Business statements must include a classified balance sheet.
o
It is highly recommended that personal statements include a supplemental schedule disclosing working capital.
• MONETARY LIMITS OF $250,000 OR MORE:
o
A financial statement that is prepared and reviewed or audited by an independent certified public accountant,
current within 1 year from the date the application is received.
• MONETARY LIMITS OF $50,000 OR MORE, BUT LESS THAN $250,000:
o
A compiled financial statement with full disclosures, prepared by an independent certified public accountant, current
within 6 months from the date the application is received; or
• MONETARY LIMITS OF MORE THAN $10,000, BUT LESS THAN $50,000:
o
A compiled financial statement prepared by an independent CPA, current within 6 months from the date the
application is received; or
• MONETARY LIMITS OF $10,000 OR LESS:
Self-prepared or compiled statements must be current to within 6 months from the date the application is received.
o
A current financial statement prepared by an independent CPA; or
o
A current financial statement submitted using the Board’s form online. If you are not familiar with the financial terms,
documents, or general small business requirements, please visit the Nevada Business Development Center online at:
http://nsbdc.org/ or call (800) 240-7094. This site contains important information for small business owners and allows
you to request individual counseling services, which may be helpful in completing the requested information within this
licensing application.
SECTION 12 – RESIDENTIAL RECOVERY FUND
• The State of Nevada has established a Residential Recovery Fund for the benefit of Nevada homeowners who contract
with a licensed contractor and, under certain conditions, are harmed by the failure of that contractor to properly perform
qualified services. The fund is created from assessments from contractors who participate in the construction, remodeling,
repair or improvement of residential housing. Assessments are based on the monetary limit placed on the license.
• WHO MUST REGISTER: Each residential contractor who will be providing “Qualified Services” must register with the Fund.
o
Qualified services are defined in NRS 624.440 as “any construction, remodeling, repair or improvement performed
by a residential contractor on a single-family residence occupied by the owner of the residence.”
o
A residential contractor is defined in NRS 624.450 as a contractor who contracts with the owner of a single-
family residence to perform qualified services.
1.
Will you be acting as a “residential contractor” performing “qualified services” as defined in NRS 624.440 and NRS 624.450?
NO YES
2.
Does the applicant, any officer, director, partner, proprietor, shareholder (unless publicly traded), member, owner,
qualified employee, or manager associated with or employed by the applicant have any prior recovery fund claims
paid or claims pending with Nevada or any other state?
NO YES - Please provide Claim #
Page 6 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
SECTION 13 – VETERAN OWNED BUSINESS INFORMATION
The following information is being requested for use by the Nevada Interagency Council on Veterans Affairs which collects data
related to veteran owned businesses. Include a copy of this form with your application. If a United States Veteran, or Service
Member, owns at least 51% of this company, please provide the following information for that individual.
_____________________________ _________________________________ __________________________________
First Name Middle Name Last Name
________________________________________________ __________________________
Business Name License Number (if applicable)
1. Branch of Service, including reserves: Check all that apply.
Army
Marine Corps
Navy
Air Force
Coast Guard
National Guard
2. Military Occupation Specialty/Specialties: _________________________________________________________________________
3. Date of Services (Month/Day/Year): From: ____/___ / ___ To: ____/ __/_
4. Have you ever served on active duty in the Armed Forces of the United States and separated from such service under conditions
other than dishonorable? YES NO
5. Have you ever been assigned to duty for a minimum of 6 continuous years in the National Guard or a reserve component of the Armed
Forces of the United States and separated from such service under conditions other than dishonorable? YES NO
6. Have you ever served the Commissioned Corps of the United States Public Health Service or the Commissioned Corps of the National
Oceanic and Atmospheric Administration of the United States in the capacity of a commissioned officer while on active duty in defense
of the United States and separated from such service under conditions other than dishonorable? YES NO
Thank you for your service to our country!
SECTION 15 – CONSTRUCTION EDUCATION FUND
• The Nevada Legislature created a Construction Education Fund for the purpose of supporting programs of education which
relate to building construction. Administrative fines collected by the Board have been “earmarked” for this fund. In addition,
individuals may make voluntary contributions. If you would like to make a voluntary contribution, please submit a separate
check made out to “NSCB” and indicate the fee should be for the Construction Education Fund.
SECTION 16 – AFFIDAVIT AND AUTHORIZED SIGNATURE
I am authorized to sign this Affidavit and Release Authorization on behalf of the applicant described and identified in this
application.
The applicant is qualified in all respects for the license for which it is applying in this application.
To the best of applicant’s knowledge, the information contained in the application and its supporting documents are free of fraud,
misrepresentation, or omission of material fact. To the best of applicant’s knowledge, the information contained in the application
and its supporting documents are truthful, correct, and complete; and, discloses all material facts regarding the applicant and
associated individuals necessary to properly evaluate the applicant’s qualification for licensure.
Applicant will ensure that any information subsequently submitted to the Board in conjunction with this application or its
supporting documents meet the same standard as set forth above.
Applicant understands that to apply for or obtain a license or to otherwise deal with the Nevada State Contractors Board through
the use of fraud, forgery, intentional deception, misrepresentation, misstatement, or omission is cause for denial of this
application.
Applicant understands that this application will be classified as a public record and will be available for inspection by the public,
except with regard to the release of information classified as confidential pursuant to NRS 624.110. Confidential information includes
credit reports, references, financial information, and investigative memoranda.
Applicant understands that the Nevada State Contractors Board has the authority to conduct appropriate background investigations
for the purpose of verifying all statements and facts represented in this application and supporting documentation.
• SIGNATURE REQUIREMENTS: A principal (listed in Section 4) must sign this application.
By: _________________________________________________________ Date:
(Signature)
(Print Name)
FOR OFFICIAL USE ONLY
Indv/Org#___________________
Entered Date________________
By_________________________
Page 7 of 7
Nevada State Contractors Board (Revised 12/2021)
New License Application
FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SPACE
Date Received: Application Fee Paid: Receipt #:
App. No.
Withdrawn: Date: Reason: Approved:
Org ID.
Limit: Bond Amount: CPB Amount:
Analyst
Bond #: Effective Date: Surety: Agent: Entered by:
Industrial Insurance: Proof of Coverage Provided
Certificate of Exemption
Date:
Recovery Fund:
Participant
Certificate of Exemption Date
License Fee Paid: Receipt #: Date Paid:
Issue Date: License Number: FS Review Year:
Indemnitor: Effective:
Name Change: Entity Type Change:
QI: CMS TRD; Org#: Type: PQ New Broaden Status: A D
W
QI: CMS TRD; Org#: Type: PQ New Broaden Status: A D W
Nevada State Contractors Board
Background Disclosure Statement and Fingerprint Waiver (Revised 12/2021)
Page 1 of 2
NEV
ADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE
STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
A separate form MUST be completed by EACH Person including the Qualified Individual
BUSINESS NAME: ______________________________________________________
NRS 624.263 and NRS 624.265 authorizes the Nevada State Contractors Board (NSCB) to conduct background
investigations, obtain credit reports, and to request fingerprints for submission to the Nevada Highway Patrol (NHP) and the
FBI for a determination of identity, fugitive status or prior criminal history.
FIRST NAME
MIDDLE NAME
LAST NAME
SUFFIX
OTHER NAME USED
DATE OF BIRTH
CITY & STATE OF BIRTH
SEX
RACE
WEIGHT
HAIR COLOR
EYE COLOR
EMAIL ADDRESS (CANNOT BE A THIRD PARTY)
RESIDENCE ADDRESS (AND MAILING ADDRESS IF DIFFERENT)
CITY
STATE
ZIP
SOCIAL SECURITY NUMBER
- -
OR INDIVIDUAL TAX ID NUMBER
9
- -
A COPY OF THE FOLLOWING MUST BE PROVIDED WITH THIS FORM:
• A valid Driver’s License or Government Issued Photo I.D.
FINGERPRINT AND CRIMINAL BACKGROUND CHECKS
The NSCB will conduct a background check using information from the Federal Bureau of Investigations (FBI) and the Nevada Criminal History
Repository. These records are likely to include all instances of criminal activity, including those matters that may have been sealed, expunged, had the
charges
reduced or dismissed. If a criminal history is found, an investigation will be conducted and you will be requested to provide supporting
documentation.
1. Hav
e you ever been convicted of, or pled guilty or no contest to any crime, or, are any criminal charges pending against you?
No Yes
Applications are not automatically denied because of information obtained through the background disclosure and criminal history verification. When
reviewing prior criminal convictions, the NSCB considers such additional factors as the seriousness of the crime, the time that has passed since the
conviction and any evidence of rehabilitation the applicant submits. It is your responsibility to provide any supporting documentation requested by the
Board related to any past convictions or pending criminal charges.
FINANCIAL DISCLOSURES
2. Within the last 3 years, have you filed or been adjudicated Bankrupt under your individual name, a corporate name or any other business entity
name?
No Yes – Attach a complete copy of the proceedings, including a schedule of creditors listed in the bankruptcy petition. If the
bankruptcy has not been discharged, include your plan of reorganization and proof of compliance.
3. Do you anticipate filing bankruptcy within the next 6 months?
No Yes
4. Have you, or any business entities of which you were a member, partner, officer, director, or associate received any notice of liens, suits,
judgments, or claims (including tax claims) which remain unresolved or unsatisfied – OR – Are there now any unpaid past due bills for
materials, services rendered, or labor?
No Yes – Attach a detailed explanation.
5. Have you, or any business entities of which you were a member, partner, officer, director, associate, or qualified employee had a contractor’s
license denied, suspended, revoked, or otherwise disciplined BY NEVADA OR ANY OTHER STATE? Are there any disciplinary proceedings
currently pending against you, or any license on which you have appeared IN NEVADA OR ANY OTHER STATE?
No Yes – Attach a detailed explanation including the name of the state in which the license was held, license number, and
business name.
6. Do you have a proprietary interest (i.e., ownership, stock, shares) in this applicant? (This question does not pertain to sole proprietors).
No Yes – Percentage Owned: ________%
For Board Staff Only
Live Scan Prints
Hard Copy Prints
Nevada State Contractors Board
Background Disclosure Statement and Fingerprint Waiver (Revised 12/2021)
Page 2 of 2
In order to comply with the requirements of Nevada’s Department of Public Safety, fingerprint cards and LiveScan fingerprints cannot be
accepted until after you submit your application and completed Fingerprint Background Waiver form(s) to the Board.
Once these forms has been submitted to the Nevada State Contractors Board you may proceed with obtaining the required fingerprints.
In c
onsideration for processing my application for a Nevada State Contractor’s License, I, the undersigned whose name and personal
information voluntarily appear above, do hereby and irrevocably agree to the following:
1. I her
eby authorize the NEVADA STATE CONTRACTORS BOARD (hereinafter “BOARD”) to submit a set of my fingerprints to the
Nevada Department of Public Safety, Records Bureau for the purpose of accessing and reviewing Nevada and National criminal history
records that may pertain to me. In giving this authorization, I expressly understand that the information may include information pertaining
to notations of arrest, detainments, indictments, information or other charges for which the final court disposition is pending or is unknown
to the above referenced agencies. For records containing final court disposition information, I understand that the release may include
information pertaining to dismissals, acquittals, convictions, sentences, correctional supervision information and information concerning the
status of my parole or probation when applicable. Further, I understand that the information may include similar information obtained from
other local, state and federal criminal justice agencies and may include information pertaining to convicted person data, outstanding arrest
warrants, missing persons and current and/or prior gaming and non-gaming sheriff’s work cards that were issued to me.
2. I under
stand that I may review and challenge the accuracy of any and all criminal history records which are returned to the BOARD.
3. I her
eby release from liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, the Nevada
State Contractors Board, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and provided
information to the BOARD for any statement(s), omission(s), or infringement(s) upon my current legal rights. I further release and promise
to hold harmless and covenant not to sue any persons, firms, institutions or agencies providing such information to the State of Nevada
and the BOARD on the basis of their disclosures. I have signed this release voluntarily and of my own free will.
4. In gi
ving the above authorization, I understand that all information provided to the BOARD may be reviewed by the BOARD or any other
employee within the BOARD’S organization deemed necessary to make an informed decision. This information is confidential, as relating
to a third party beyond that of the BOARD and of the criminal justice agencies in the performance of their official duties, and may not be
further disseminated.
A reproduction of this authorization for release of information by photocopy, facsimile or similar process, shall for all purposes be as
valid as the original.
PURSUANT TO NRS 199.120, I CERTIFY THAT I HAVE CAREFULLY REVIEWED THE INFORMATION CONTAINED IN THIS
DOCUMENT AND I ATTEST TO THE TRUTH AND ACCURACY OF THE INFORMATION CONTAINED IN THIS BACKGROUND
DISCLOSURE STATEMENT UNDER PENALTY OF PERJURY.
Signature: ____________________________________________ Date: _______________________
0505RCCD-003(08/2020rev)
Fingerprint Background Waiver Page 1 of 2
Fingerprint Background Waiver
As an applicant who is the subject of a national fingerprint-based criminal history record check for a
noncriminal justice purpose (such as an application for employment or a license, an immigration or
naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.
All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974,
Title 5, United States Code (U.S.C.) Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12,
among other authorities.
1. You must be notified by Nevada State Contractors Board (name of requesting agency) that your
fingerprints will be used to check the criminal history records of the FBI and the State of Nevada.
2. Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information
is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental
authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive
Orders, and federal regulations. Providing your fingerprints and associated information is voluntary;
however, failure to do so may affect completion or approval of your application.
3. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible
agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s
Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and
latent fingerprint repositories) or other available records of the employing, investigating, or otherwise
responsible agency. The FBI and/or the Central Repository for Nevada Records of Criminal History
may retain your fingerprints and associated information/biometrics in NGI after the completion of this
application and, while retained, your fingerprints may continue to be compared against other
fingerprints submitted to or retained by NGI.
4. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints
and associated information/biometrics are retained in NGI
and/or Central Repository for Nevada
Records of Criminal History, your information may be disclosed pursuant to your consent, and may be
disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses
as may be published at any time in the Federal Register, including the Routine Uses for the NGI system
and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to:
employing, governmental or authorized non-governmental agencies responsible for employment,
contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or
federal law enforcement agencies; criminal justice agencies; and agencies responsible for national
security or public safety.
5. If you have a criminal history record, you should be afforded a reasonable amount to time to correct or
complete the record (or decline to do so) before the officials deny you the employment, license, or
other benefit based on information in the FBI criminal history record. The procedures for obtaining a
change, correction, or update of your FBI criminal history record as set forth at, 28 CFR 16.34 provides
for the proper procedure to do so.
Applicant:
Initial Date
__________________ ___________________
0505RCCD-003(08/2020rev)
Fingerprint Background Waiver Page 2 of 2
6. If agency policy permits, the officials may provide you with a copy of your FBI criminal history
record for review and possible challenge. If agency policy does not permit it to provide you a copy
of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/
identity-history-summary-checks and https://www.edo.cjis.gov .
7. If you decide to challenge the accuracy or completeness of your FBI criminal history record, you
should send your challenge to the agency that contributed the questioned information to
the FBI. Alternatively, you may send your challenge directly to the FBI by submitting a
request via https://www.edo.cjis.gov . The FBI will then forward your challenge to the agency that
contributed the questioned information and request the agency to verify or correct the challenged
entry. Upon receipt of an official communication from that agency, the FBI will make any necessary
changes/corrections to your record in accordance with the information supplied by that agency.
(See 28 CFR 16.30 through 16.34.)
8. You have the right to expect that officials receiving the results of the fingerprint-based criminal
history record check will use it only for authorized purposes and will not retain or disseminate it in
violation of federal or state statute, regulation or executive order, or rule, procedure or standard
established by the National Crime Prevention and Privacy Compact Council.
9. I hereby authorize Nevada State Contractors Board (name of requesting agency), to submit a set of
my fingerprints to the Nevada Department Public Safety, Records Bureau for the purpose of
accessing and reviewing State of Nevada and FBI criminal history records that may pertain to me.
10. I hereby release from liability and promise to hold harmless under any and all causes of legal action,
the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal
history records search and provided information to the submitting agency for any statement(s),
omission(s), or infringement(s) upon my current legal rights. I further release and promise to hold
harmless and covenant not to sue any persons, firms, institutions or agencies providing such
information to the State of Nevada on the basis of their disclosures. I have signed this release
voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar process,
shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature voluntarily
appears below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEA
SE PRINT
Last Name First Name Middle
Applicant’s Signature:
Date:
Agency Account #:
Agency Representative:
PLEASE PRINT
Last Name First Name Middle
Agency Representative Signature:
Date:
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
Nevada State Contractors Board (Revised 12/2021)
Certification of Work Experience
Page 1 of 1
CERTIFICATION OF WORK EXPERIENCE
*PART 1: QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION: The qualifying individual must complete Part 1 in its entirety
before the certifier completes Part 2.
APPLICANT’S FULL LEGAL NAME: _______________________ _____________________ ___________________ _________
(FIRST) (MIDDLE) (LAST) (SUFFIX)
CLASSIFICATION OF LICENSE REQUESTED (Code and Description)
PLEASE INDICATE YOUR BUSINESS RELATIONSHIP TO THE CERTIFIER AT THE TIME EXPERIENCE WAS GAINED
Supervisor Foreman Journeyman Contractor Employee Supplier
*PART 2: WORK EXPERIENCE AND CERTIFICATION STATEMENT: The certifier must complete Part 2 in its entirety after the
qualifying individual (applicant) has completed Part 1.
CHECK THE BOX THAT IDENTIFIES THE LEVEL OF WORK PERFORMED BY THE INDIVIDUAL ABOVE (APPLICANT)
Supervisor Foreman Journeyman Contractor Employee
Full-Time Part-Time
FROM: ________________________ TO: ______________________ = _________ YEAR(S) AND _________ MONTHS
(month/day/year) (month/day/year)
(Do not claim credit for full-time work if applicant worked only part-time or if trade duties in requested classification were only
one component of entire job)
In the space below, list all specific trade duties applicant performed or supervised in the classification or trade area listed in
Part 1 above. If additional space is required, provide a signed attachment by the certifier.
IMPORTANT: You may be requested to provide documentation to verify all experience to which you are attesting. For your records, it
is suggested that you keep a copy of the certificate(s) you have completed.
I certify that I have direct knowledge of the stated individual’s work experience during the time period outlined above. I certify under
penalty of perjury to the truth and accuracy of the statements and information contained herein and understand that these statements
are subject to verification. (*REQUIRED FIELDS)
____________________________________________ ____________________ ___________________________________
*Signature of Certifier Date *Printed Name of Certifier
____________________________________________________________ _____________________ ______________
Company or Business Affiliation License No(s). State
___________________________________________________________________________________________________________
*Address *City *State *Zip
____________________________________ ___________________________ ___________________________________
*Daytime Phone Number Fax Number *E-mail Address
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
Nevada State Contractors Board (Revised 12/2021)
Certification of Work Experience
Page 1 of 1
CERTIFICATION OF WORK EXPERIENCE
*PART 1: QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION: The qualifying individual must complete Part 1 in its entirety
before the certifier completes Part 2.
APPLICANT’S FULL LEGAL NAME: _______________________ _____________________ ___________________ _________
(FIRST) (MIDDLE) (LAST) (SUFFIX)
CLASSIFICATION OF LICENSE REQUESTED (Code and Description)
PLEASE INDICATE YOUR BUSINESS RELATIONSHIP TO THE CERTIFIER AT THE TIME EXPERIENCE WAS GAINED
Supervisor Foreman Journeyman Contractor Employee Supplier
*PART 2: WORK EXPERIENCE AND CERTIFICATION STATEMENT: The certifier must complete Part 2 in its entirety after the
qualifying individual (applicant) has completed Part 1.
CHECK THE BOX THAT IDENTIFIES THE LEVEL OF WORK PERFORMED BY THE INDIVIDUAL ABOVE (APPLICANT)
Supervisor Foreman Journeyman Contractor Employee
Full-Time Part-Time
FROM: ________________________ TO: ______________________ = _________ YEAR(S) AND _________ MONTHS
(month/day/year) (month/day/year)
(Do not claim credit for full-time work if applicant worked only part-time or if trade duties in requested classification were only
one component of entire job)
In the space below, list all specific trade duties applicant performed or supervised in the classification or trade area listed in
Part 1 above. If additional space is required, provide a signed attachment by the certifier.
IMPORTANT: You may be requested to provide documentation to verify all experience to which you are attesting. For your records, it
is suggested that you keep a copy of the certificate(s) you have completed.
I certify that I have direct knowledge of the stated individual’s work experience during the time period outlined above. I certify under
penalty of perjury to the truth and accuracy of the statements and information contained herein and understand that these statements
are subject to verification. (*REQUIRED FIELDS)
____________________________________________ ____________________ ___________________________________
*Signature of Certifier Date *Printed Name of Certifier
____________________________________________________________ _____________________ ______________
Company or Business Affiliation License No(s). State
___________________________________________________________________________________________________________
*Address *City *State *Zip
____________________________________ ___________________________ ___________________________________
*Daytime Phone Number Fax Number *E-mail Address
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
Nevada State Contractors Board (Revised 12/2021)
Certification of Work Experience
Page 1 of 1
CERTIFICATION OF WORK EXPERIENCE
*PART 1: QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION: The qualifying individual must complete Part 1 in its entirety
before the certifier completes Part 2.
APPLICANT’S FULL LEGAL NAME: _______________________ _____________________ ___________________ _________
(FIRST) (MIDDLE) (LAST) (SUFFIX)
CLASSIFICATION OF LICENSE REQUESTED (Code and Description)
PLEASE INDICATE YOUR BUSINESS RELATIONSHIP TO THE CERTIFIER AT THE TIME EXPERIENCE WAS GAINED
Supervisor Foreman Journeyman Contractor Employee Supplier
*PART 2: WORK EXPERIENCE AND CERTIFICATION STATEMENT: The certifier must complete Part 2 in its entirety after the
qualifying individual (applicant) has completed Part 1.
CHECK THE BOX THAT IDENTIFIES THE LEVEL OF WORK PERFORMED BY THE INDIVIDUAL ABOVE (APPLICANT)
Supervisor Foreman Journeyman Contractor Employee
Full-Time Part-Time
FROM: ________________________ TO: ______________________ = _________ YEAR(S) AND _________ MONTHS
(month/day/year) (month/day/year)
(Do not claim credit for full-time work if applicant worked only part-time or if trade duties in requested classification were only
one component of entire job)
In the space below, list all specific trade duties applicant performed or supervised in the classification or trade area listed in
Part 1 above. If additional space is required, provide a signed attachment by the certifier.
IMPORTANT: You may be requested to provide documentation to verify all experience to which you are attesting. For your records, it
is suggested that you keep a copy of the certificate(s) you have completed.
I certify that I have direct knowledge of the stated individual’s work experience during the time period outlined above. I certify under
penalty of perjury to the truth and accuracy of the statements and information contained herein and understand that these statements
are subject to verification. (*REQUIRED FIELDS)
____________________________________________ ____________________ ___________________________________
*Signature of Certifier Date *Printed Name of Certifier
____________________________________________________________ _____________________ ______________
Company or Business Affiliation License No(s). State
___________________________________________________________________________________________________________
*Address *City *State *Zip
____________________________________ ___________________________ ___________________________________
*Daytime Phone Number Fax Number *E-mail Address
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
Nevada State Contractors Board (Revised 12/2021)
Certification of Work Experience
Page 1 of 1
CERTIFICATION OF WORK EXPERIENCE
*PART 1: QUALIFYING INDIVIDUAL (APPLICANT) INFORMATION: The qualifying individual must complete Part 1 in its entirety
before the certifier completes Part 2.
APPLICANT’S FULL LEGAL NAME: _______________________ _____________________ ___________________ _________
(FIRST) (MIDDLE) (LAST) (SUFFIX)
CLASSIFICATION OF LICENSE REQUESTED (Code and Description)
PLEASE INDICATE YOUR BUSINESS RELATIONSHIP TO THE CERTIFIER AT THE TIME EXPERIENCE WAS GAINED
Supervisor Foreman Journeyman Contractor Employee Supplier
*PART 2: WORK EXPERIENCE AND CERTIFICATION STATEMENT: The certifier must complete Part 2 in its entirety after the
qualifying individual (applicant) has completed Part 1.
CHECK THE BOX THAT IDENTIFIES THE LEVEL OF WORK PERFORMED BY THE INDIVIDUAL ABOVE (APPLICANT)
Supervisor Foreman Journeyman Contractor Employee
Full-Time Part-Time
FROM: ________________________ TO: ______________________ = _________ YEAR(S) AND _________ MONTHS
(month/day/year) (month/day/year)
(Do not claim credit for full-time work if applicant worked only part-time or if trade duties in requested classification were only
one component of entire job)
In the space below, list all specific trade duties applicant performed or supervised in the classification or trade area listed in
Part 1 above. If additional space is required, provide a signed attachment by the certifier.
IMPORTANT: You may be requested to provide documentation to verify all experience to which you are attesting. For your records, it
is suggested that you keep a copy of the certificate(s) you have completed.
I certify that I have direct knowledge of the stated individual’s work experience during the time period outlined above. I certify under
penalty of perjury to the truth and accuracy of the statements and information contained herein and understand that these statements
are subject to verification. (*REQUIRED FIELDS)
____________________________________________ ____________________ ___________________________________
*Signature of Certifier Date *Printed Name of Certifier
____________________________________________________________ _____________________ ______________
Company or Business Affiliation License No(s). State
___________________________________________________________________________________________________________
*Address *City *State *Zip
____________________________________ ___________________________ ___________________________________
*Daytime Phone Number Fax Number *E-mail Address
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
RESUME OF EXPERIENCE
EXPERIENCE RECORD OF: _______________________________________________________
(Print name of qualified individual)
Employer’s Name:__________________________________________________ Phone:______________________________
Address: __________________________________________________________ E-mail:______________________________
(Street, City, State, Zip)
Date of Employment: From: ________________ To: ________________
(month/day/year) (month/day/year)
Check all jobs held for this employer:
Journeyman Foreman Supervisor Contractor Self-Employed Other:______________________
Employer’s Name:__________________________________________________ Phone:______________________________
Address: __________________________________________________________ E-mail:______________________________
(Street, City, State, Zip)
Date of Employment: From: ________________ To: ________________
(month/day/year) (month/day/year)
Check all jobs held for this employer:
Journeyman Foreman Supervisor Contractor Self-Employed Other:______________________
Employer’s Name:__________________________________________________ Phone:______________________________
Address: __________________________________________________________ E-mail:______________________________
(Street, City, State, Zip)
Date of Employment: From: ________________ To: ________________
(month/day/year) (month/day/year)
Check all jobs held for this employer:
Journeyman Foreman Supervisor Contractor Self-Employed Other:______________________
DESCRIBE IN DETAIL THE SPECIFIC TYPE AND/OR SCOPE OF WORK PERFORMED
Full-Time
Part-Time (specify aggregate total)
______ Years _______ Months
DESCRIBE IN DETAIL THE SPECIFIC TYPE AND/OR SCOPE OF WORK PERFORMED
Full-Time
Part-Time (specify aggregate total)
______ Years _______ Months
DESCRIBE IN DETAIL THE SPECIFIC TYPE AND/OR SCOPE OF WORK PERFORMED
Full-Time
Part-Time (specify aggregate total)
______ Years _______ Months
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
Request for Verification of Licensure (Revised 12/2021)
Request for Verification of Licensure
APPLICANT INFORMATION
INSTRUCTION TO APPLICANT: Complete the Applicant Information portion of this request. Give the form to the appropriate
agency. The verifying agency will mail the completed verification to you at the address you have listed. Include the completed
form with
your application.
Applicant Business Name__________________________________________________________________________________
Full Legal Name of Qualifier_______________________________________________________________ | ________________
First Middle Last Date of Birth
Mailing Address _________________________________________________________________________________________
Street/P O Box City State/Zip
License Number _________________________________________ State ___________________________________
I authorize you to release, to the State of Nevada, all information pertaining to the above license number.
_______________________________________________
Signature
NOTE TO APPLICANT: COMPLETE A SEPARATE FORM FOR EACH LICENSE NUMBER
LICENSE INFORMATION
TO VERIFYING STATE: Please furnish the information requested. Sign and verify the document. Place the completed form in an
envelope, seal the envelope, and provide it to the applicant either in person or by mail.
Business Name _________________________________________________________________________________________
Name of Qualified Person ______________________________________________ Date Added to License_________________
Classification of License Issued: (code and description) ___________________________________________________________
License Number _____________________________________ Current Status ______________________________________
Original Date of Issue _________________________________ Expiration Date______________________________________
Continuously Licensed? Yes No. If no, please explain ________________________________________________________
Licensed by: Exam. Type ____________________________ Score _________________ Date ____________________
Endorsement from the State of: ___________________________________
Waiver. Please state basis of waiver: _______________________________
Experience Required for Licensure __________________________________________________________________________
Is there a record of disciplinary action or pending disciplinary action against this license?
No Yes. If yes, please attach a copy of the action.
Name of Verifying Official _____________________________________ _______________________________________
Print Name Signature
Title ______________________________________
{Agency Seal}
Agency ___________________________________
Date ______________________________________
click to sign
signature
click to edit
NEVADA STATE CONTRACTORS' BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NV, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
8400 WEST SUNSET ROAD, SUITE 150, LAS VEGAS, NV, 89113 (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
www.nscb.nv.gov
CHILD SUPPORT INFORMATION STATEMENT
In compliance with State and Federal law, applications applying for licensure as an Individual
are required complete and submit this Child Support Information Statement with their
application for contractor’s license.
Please mark the appropriate response and provide all other information requested on the form.
I am not subject to a Court Order for the support of a child.
I am subject to a Court Order for the support of one or more children and I am in
compliance with that Order; or I am in compliance with a plan approved by the District
Attorney or other public agency enforcing the Order for the repayment of the amount
owed pursuant to that Order.
I am subject to a Court Order for the support of one or more children and I am not in
compliance with the Order or a plan approved by the District Attorney or other public
agency enforcing the Order for the repayment of the amount owed pursuant to that
Order. Note: If you have marked this response you should contact the District Attorney
or other public agency enforcing the order to determine the actions that you may take to
satisfy the Order.
I certify, under penalty of perjury to the truth and accuracy of all statement contained herein.
____________________________
(Signature)
__________________
________________________
(Print Name)
__________________________________________
(Social Security Number)
Date: _____________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

A check, cashiers check, or money order in (Nevada State Contractors Board)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document