Please complete each Section accordingly
1. Section 1.1, complete business information to include name of qualifier, business name,
license number according to construction trade and expiration date.
2. Section 2.1, provide agent identifying information; use legal name (no nicknames) as
printed on your government issued ID.
3. Section 2.2, provide agent physical address, P.O. Boxes are not acceptable
4. Section 3.1, print information of whom the license holder is allowing to become an agent
on his behalf.
5. Section 4.1, check off box acknowledging statement.
6. Section 5.1, signature of qualifier is required.
7. Section 5.2, notarization of qualifiers signature.
8. Section 5.3, signature of authorized agent required.
9. Section 5.4, notarization of agent’s signature.
10. Please submit form to email provided, mail back or drop off with copies of identification
for person named in Section 1 & Section 2. Acceptable identification:
A legible copy of your current drivers’ license, State I.D., passport, or green card displaying
photo, current address and signature. If no current address on identification, then proof of
current address must be provided such as a current utility bill.
11. 1
st
time enrollee’s with Palm Beach County’s Building Department to pull permits as an
agent will be required to drop this information off in person for verification, otherwise
information may be dropped off, mailed, or emailed to Contractors Certification by
including form and identifications. (Faxes are not acceptable)
12. Please Note: Agent forms are only good until the expiration period outlined in Section 1.
13. Agent Form will have a validity of 30 days from notarization; the form will then become
null and void for acceptance.
14. Incomplete forms with blank spaces cannot be completed on site, this will invalidate the
notarization.
15. It is the responsibility of each notary to know how to complete the notary section.
