STATE CERTIFIED CONTRACTOR REGISTRATION FORM
Charlotte County
Community Development Department
Building Construction Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
Email: ContractorLicensing@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
"To exceed expectations in the delivery of public services"
Please submit the following documents listed below. All items must be included and can be mailed or hand delivered to process
the registration. Allow three (3) business days for processing mailed documents.
1. Copy of current state license.
2. A Local Business Tax Receipt from qualifiers home county.
3. Current drivers license.
4. Certificate of Insurance for General Liability and Worker's Compensation or qualifiers exemption card.
Certificate must list Charlotte County Community Development as certificate holder.
5. Current head shot type photo.
Please remember - bring or mail all of the above items on the checklist together as a package with the completed registration
form.
**** Note: We CANNOT accept email or fax copies. Please mail or hand deliver original.****
(Power of Attorney not accepted)
STATE OF FLORIDA County of ___________________
The foregoing instrument was acknowledged before me this ______ day of ________, 20__ by ___________________________
who is personally known to me or has produced __________________ as identification and who did/did not take an oath.
Signature of Notary ____________________________________
Notary's Printed Name ______________________________
Commission Number ______________
CERTIFICATE HOLDER'S NAME:
NAME OF BUSINESS:
CERTIFICATE CLASSIFICATION:
CERTIFICATE NUMBER:
FEDERAL I.D. NUMBER: BIRTH DATE:
BUSINESS ADDRESS:
BUSINESS MAILING ADDRESS:
HOME ADDRESS:
BUSINESS PHONE: HOME PHONE:
CERTIFICATE HOLDER'S SIGNATURE:
Notary Stamp
FAX NUMBER: EMAIL ADDRESS:
Identification Number & Expiration Date:
March 2018
