IBOL-CON RCE- 03/2020
APPLICATION FOR A CONTRACTOR BUSINESS ENTITY REGISTRATION
(continued)
11. List the primary type of construction (Ref #) ___________(Use attached list and choose only one category that best describes your business.)
12. Th
e entity must hold a certificate of current, effective general liability insurance including products and completed
operations coverage of not less than $300,000.00 single limit. Does the entity hold current liability insurance? If yes, please attach
the certificate of liability insurance. If not your application cannot be processed until this information is received. [ ] Yes [ ] No
THE APPLICANT NAME (above) AND THE INSURED NAME (on your certificate) SHOULD MATCH.
13. D
oes the entity hold a current, effective worker’s compensation insurance policy? [ ] Yes [ ] No
If Yes, you must attach the certificate.
THE APPLICANT NAME (above) AND THE INSURED NAME (on your certificate of insurance) SHOULD MATCH.
If No, explain below as to why such coverage is not required under the laws governing worker’s compensation (Idaho Code §§ 72-101
– 72-230). For information or questions about workers compensation, please contact the Industrial Commission on the web
https://iic.idaho.gov/employer-compliance-division/, by email at suretyrequest@iic.idaho.gov
or by phone at the Employer Compliance General
Phone Number: 208-334-6060.
_________________________________________________________________________________________________________
Explanation of why such coverage is not required
Please note that in questions number 14, 15, and 16, the phrase “anyone with an interest in the applicant” refers to interests owned by an
individual, firm, partnership, limited liability company, limited liability partnership, corporation, trust, association, or other entity or
organization capable of conducting business, or any combination thereof acting as a unit. The phrase “any jurisdiction” refers to the federal
government or any city, county or state including Idaho.
14. Has the applicant or anyone with an interest in the applicant ever been licensed or registered as a contractor in any state,
including Idaho, or other jurisdiction? [ ] Yes [ ] No
(If Yes, identify and list below who has been licensed or registered, the jurisdiction and license/registration numbers.)
_________________________________________________________________________________________________________
15. H
as the applicant or anyone with an interest in the applicant ever had a contractor license or registration denied,
surrendered, suspended, revoked, or otherwise disciplined in any state, including Idaho, or other jurisdiction? [ ] Yes [ ] No
(If Yes, a copy of the charges and final order must be received by the Board directly from each issuing authority; also attach a detailed statement of
explanation from the individual or entity involved which includes the jurisdiction, the license/registration number(s), the allegations if you are aware
of them, and any other relevant information.)
16. Ha
s the applicant or anyone with an interest in the applicant ever received a conviction, finding of guilt, withheld
judgment or suspended sentence for any felony
in any state, including Idaho, or other jurisdiction? [ ] Yes [ ] No
(If yes, the Criminal Conviction Disclosure Form, official court documents, and probation and parole documents along with any other relevant
information must be received with this application.)
AFFIDAVIT
Upon oath I certify each of the following: (1) the responses and information provided in this application and in the attached addendum(s) and
documentation are true and correct to the best of my knowledge; (2) I am the applicant named in and who has signed this application; (3) I am a
United States citizen or a legal permanent resident or I am otherwise lawfully present in the United States; (4) I have read and will conform to the
Laws and Rules governing the profession for which I am seeking a license or authority to practice; (5) I acknowledge and agree the use of intentional
misrepresentation or fraud in this application or violation of any Laws or Rules governing the profession for which I am seeking a license or authority
to practice shall constitute cause sufficient for denial, suspension, cancellation or revocation of any license or authority applied for or granted to me;
(6) I will provide additional or corrected information if material changes occur which would cause responses or information provided in or with this
application to be inaccurate or incomplete; (7) I authorize and direct any person, agency, firm, or other entity to release, upon the request of the
Idaho Division of Occupational and Professional Licenses or its authorized representative, any information, communication, report, record,
statement, disclosure, or recommendation that may have bearing on my eligibility for or maintenance of the license or authority for which I am
applying and hereby release and exonerate any of them from any liability of any kind resulting from the release or collection thereof; and
(8) I authorize the Division of Occupational and Professional Licenses to release to any other regulatory entity in any jurisdiction any
information requested about me that may otherwise be protected or confidential that may have bearing on my eligibility for or maintenance of
any license or authority issued or applied for in this or any jurisdiction and hereby release and exonerate them from any liability of any kind
resulting from the release thereof.
_____________________________________________ ________________________________________________________
Print Owner, Authorized Agent or Officer Name Signature of Owner, Authorized Agent or Officer
Note: Please print and sign your full legal name
State of _______________, County of ___________________, ss
Subscribed and sworn before me this _____ day of ______________________________, 20 ___
(seal) Notary Public Official Signature
My Commission Expires
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