Fillable CONTRACTORS LICENSING RECIPROCITY APPLICATION CHECKLIST

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CONTRACTORS LICENSING RECIPROCITY APPLICATION CHECKLIST

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HERNANDO COUNTY
CONTRACTORS LICENSING
RECIPROCITY APPLICATION CHECKLIST
NAME OF APPLICANT: ____
____________________________________________________
D
/B/A:_________________________________________________________________________
TYPE OF LICENSE APPLIED FOR: ______________________________________________
Reciprocity may be granted to contractors who have been licensed in another jurisdiction within the State of Florida,
and meet the minimum certification requirements set forth in Hernando County Ordinance 2015-11. Approved
contractors may be issued a certificate of competency for the trade being applied for, which is equal to, in all
respects, certificates issued in accordance with Hernando County Code of Ordinance. To be considered for
reciprocity, the applicant shall submit the following:
______ 1. A Letter of Reciprocity from the jurisdiction responsible for initial licensing. Letter of
reciprocity shall include: length of licensure, test score results from a proctored Florida testing firm with a
minimum test score of 75 % percent on both the trade exam and the business and law exam, complaint
background, current status of license, and a statement that the license has not been suspended or revoked
within four (4) years
prior to the application for reciprocity.
Your letter of reciprocity must show you have four (4) years minimum experience. If your
letter shows you have had a license for at least four (4) years, you qualify. If your letter states you were
required to show four (4) years to get your license, you qualify. If your letter demonstrates a
combination of either equaling four (4) years, you qualify.
______ 2. Remittance of non-refundable application/background check fee. Contact Department for
current fee.
_______ 3. Proof of compliance with workers’ compensation law.
_______ 4. Proof of liability insurance with Hernando County as the certificate holder to be submitted within
thirty (30) days of license approval.
_______ 5. Completed application form for reciprocity.
_______ 6. Completed Choice Point Questionnaire. (This will be used to request criminal background
search)
______ 7.
Copy of State License if applicable.
______ 8.
One copy of a valid driver’s license or valid identification card.
______ 9.
Upon approval of application, remittance of the applicable license fee. Contact Deparment
for current fee.
______ 10. Copy of Articles of Incorporation with all officers listed if applicable.
______ 11. Copy of Articles in Organization with all directors listed if applicable.
Reciprocity may be denied to an applicant if any provision of this section is not complied
with, or the applicant fails to meet the minimum certification requirements for the license
being applied for.
If appearance before the Board of Construction & Regulation is requested or required and
your application is denied, You must wait 6 months before reapplying.
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HERNANDO COUNTY APPLICATION
FOR RECIPROCITY LICENSE
ALL INFORMATION MUST BE
COMPLETED ON THE INDIVIDUAL
BEING ISSUED THE LICENSE
PLEASE TYPE OR PRINT LEGIBLY
DATE: ___/___/________ Drivers License #:________________________________________
NAME: ______________________________________________________________________
ADDRESS: ___________________________________________________________________
CITY: _________________________________ STATE: ________________ZIP: ___________
COUNTY: ___________________PHONE NUMBER: (______)_________________________
BUSINESS NAME
BUSINESS ADDRESS:
_____________________________________________________________________________
CITY: ______________________________ STATE:_____________________ ZIP:_________
BUSINESS PHONE:(___)________________ CELL/TOLL FREE:_______________________
FAX:(___)__________________________ E-MAIL: __________________________________
PLEASE BE ADVISED:
APPLICATIONS ARE VALID FOR A PERIOD OF 180 DAYS.
APPROVED APPLICATIONS ARE VALID FOR A PERIOD OF SIXTY DAYS.
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APPLICANT TO CONDUCT BUSINESS AS:
(__) INDIVIDUAL___________________ (__) CO-PARTNERSHIP_____________________
((__) CORPORATION __) OTHER_______________________________
IF OTHER, PLEASE SPECIFY: __________________________________________________
ARE THERE ANY OTHER QUALIFYING AGENTS OF THIS CORPORATION? ____Yes ___No
IF S
O WHOM _
_______________________________________________________________
____) PRIMARY OR ( ____( ) SECONDARY
IF CONDUCTING BUSINESS IN ANY FORM OTHER THAN AN INDIVIDUAL, HOW LONG
HAVE YOU BEEN THE QUALIFYING AGENT FOR THE ABOVE NAME ENTITY? ___________
PLEASE NOTE THE COMPANY NAME APPEARING ON THE
LICENSE MUST BE USED ON ALL PERMIT APPLICATIONS
***HAVE YOU THE APPLICANT EVER BEEN CONVICTED OF A CRIME, FOUND
GUILTY, OR ENTERED A PLEA OF GUILTY OR NOLO CONTENDERE (NO
CONTEST) TO, EVEN IF YOU RECEIVED A WITHHOLD OF ADJUDICATION?
( )Yes ( )No
This question applies to any violation of the laws
of any municipality, county, state or nation,
including felony, misdemeanor and traffic offenses (but not parking, speeding, inspection, or
traffic signal violations), without regard to whether you were placed on probation, had
adjudication withheld, were paroled, or pardoned. If you intend to answer “NO” because you
believe those records have been expunged or sealed by court order pursuant to Section 943.058,
Florida Statues, or applicable law of another state, you are responsible for verifying the
expunging or sealing prior to answering “NO”. YOUR ANSWER TO THIS QUESTION WILL BE
CHECKED AGAINST LOCAL, STATE AND FEDERAL RECORDS. FAILURE TO ANSWER THIS
QUESTION ACCURATELY MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE. IF YOU
DO NOT FULLY UNDERSTAND THIS QUESTION, CONSULT WITH AN ATTORNEY OR CONTACT THE
DEPARTMENT.
If “YES”, provide a certified copy of disposition for each offense.
3 of 5
FLORIDA STATUE 837.06 - FALSE OFFICIAL STATEMENTS. Whoever knowingly
makes a false statement in writing with the intent to mislead a public servant in the performance
of his official duty shall be guilty of a misdemeanor of the second degree.
I HEREBY CONFIRM THE ABOVE STATED INFORMATION IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE.
_______________________________________
Signature of License Holder
State of ___________________________
County of_________________________
The foregoing instrument was acknowledge before me this ____day of ___________,________
by_________________________________________who is (_) personally known to me, or
who (_) has produced _________________________________________ as identification.
______________________________________ __________________________________
Signature of Notary Public Notary Stamp
PLEASE RETURN FORMS TO:
HERNANDO COUNTY BUILDING DIVISION
CONTRACTOR CERTIFICATION
789 PROVIDENCE BLVD.
BROOKSVILLE, FL 34601
4 of 5
STATEMENT OF AUTHORITY TO ACT
FOR THE BUSINESS ORGANIZATION
Statement of Authority
In making application to qualify a company, corporation, partnership, limited partnership,
individual, or any type of business entity, I understand that I, as qualifying agent, am
completely responsible for the action of said business entity as they relate to its construction
business.
Further, I understand that the Hernando County Building Division holds the qualifying agent
responsible for supervision of job sites as well as all financial aspects of the entity’s construction
business including, but not limited to payment to subcontractors, payment to suppliers, payment
of applicable federal and state taxes.
Required Signatures:1.) If an Individual, the applicant
2.) If a partnership, the applicant and the partner
3.) If a corporation, the applicant and the officers of the corporation
APPLICANT:
______________________________________________________________________________
PARTNER/CORPORATE OFFICERS:
____________________________________ __________________________________
Name Title
____________________________________ __________________________________
Name Title
State of _____________________
County of ___________________
The foregoing instrument was acknowledged before me this ______day of ___________, _____,
by ______________________________________________ who is (__) personally known to me
or (__) who has produced ___________________________________________as identification.
___________________________________
Signature of Notary Public _______________________________
Notary Stamp
Reciprocity 9-15
5 of 5
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CONTRACTORS LICENSING RECIPROCITY APPLICATION CHECKLIST

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Completed 26 October 2020

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