Fillable Certificate-of-Qualification-Application-PDF Date of Application: __________

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Certificate-of-Qualification-Application-PDF Date of Application: __________

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Certificate of Qualification Application
Town Of Jackson
PO Box 1687
Jackson, Wyoming 83001
Phone: (307) 733-0520
Fax: (307) 734-3563
www.townofjackson.com
Instructions: All information on this form must be fully completed. Failure to complete any item will delay the
processing of your application. Specify the trade for which you are applying: General, Building, Residential,
Electrical, Low Voltage Electrical, Plumbing, HVAC, Wood Stove/Gas Stove Installer, Lawn Sprinkler
Installer, Water Conditioning Installer, Refrigeration, or Fire Sprinkler Installer. Specify the Type of
Certification: Master, Journeyman, or Apprentice. Provide letters of reference on the attached form. Please
complete the attached work history sheet. Provide adequate information to prove the required minimum time in
service has been completed in the trade certification for which you are applying. For detailed information on
the time in service requirements please refer to the Town of Jackson Contractor License Ordinance or call the
Town of Jackson Building Department. All payments shall be made at the time of application and shall be non-
refundable. Initial fee $50.00 Renewal fee $25.00.
New Application Renewal Updated Information If Renewal, Certificate of Qualification#______
Specify Contracting Trade :__________________(General, Building, Residential, Plumbing, HVAC, etc.)
Type of Certification _______________________________(Master, Journeyman, Apprentice)
Name:_____________________________________________Date of Birth____________________________
Mailing Address:___________________________________________________________________________
City:______________________ State:___________________ Zip Code______________________________
Phone Number (___)___________________________
The undersigned hereby certifies that the foregoing information is accurate and agrees to comply with all laws
and ordinances of the Town of Jackson applicable to the subject matter thereof.
Signed:______________________________ Date_______________________________
Office Use Only
Application Approved
Application Denied
reason:__________________________________________________________________________________
_________________________________________________________________________________________
Date
Time Engaged
From
To
Description
Present a brief narrative of your
responsibilities on the job
Years Months
Name, Address, and Phone
Number of Employer
1.
2.
3.
4.
5.
6.
7.
If you need additional space, photocopy this sheet and attach it to the application.
APPLICATION WORK HISTORY
Provide your professional experience as shown below. List all time chronologically BEGINNING wit
h
the earliest engagement after any formal education. Under time engaged enter only that time spent in
the trade for which you are applying. This portion of the application must be completed. Resumes are
not acceptable as substitutes.
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Completed 13 July 2020

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