Fillable Contractor Registration Form (City of Dania Beach)

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Contractor Registration Form (City of Dania Beach)

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The Contractor Registration Form (City of Dania Beach) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for City of Dania Beach

BROWSE CITY OF DANIA BEACH (FL) FORMS

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CONTRACTOR REGISTRATION
100 West Dania Beach Boulevard * Dania Beach, FL 33004
(954)924-6805*3651,3633 or 3652 Fax (954)922-2687
PLEASE PRINT LEGIBLY
Type of Contractor ________________________________________________________________________________
Company: Name__________________________________________________________________________________
Office Address __________________________________________________________________________________
City/State/Zip __________________________________________________________________________________
Office Phone # ___________________________________________________________________________
Qualifier: Name ___________________________________________________________________________________
Office Address ___________________________________________________________________________________
City /State/Zip ___________________________________________________________________________________
Home Phone # ____________________________________________________________________________
Owner: Name ____________________________________________________________________________________
Office Address ____________________________________________________________________________________
City/State/Zip ____________________________________________________________________________________
Home Phone # _____________________________________________________________________________
PROVIDE PHOTOCOPIES OF THE FOLLOWING DOCUMENTS
Qualifier's Driver's License ___________________________________ State: ____________
City Business Tax License ____________________________________City: _____________
County Business Tax License County: ____________________________________________
State License _____________________________________________________
Certificate of Competency _____________________________________________________
Certificates of Insurance must show the City of Dania Beach as the Certificate Holder
General Liability Expiration Date: _______________________________________________
Workers Compensation Expiration Date: __________________________________________
I hereby certify that the information contained herein is true and accurate to the best of my
knowledge.
________________________________________________
____________________________________________
Qualifier's Signature
Date
The foregoing instrument was acknowledged before me this _______ day of
__________ 20 _ _
By ________________________________________ who is personally known to me or has produced
__________________________________________ as identification and did (or did not) take an oath
_________________________________________________ My Commission Expires:
Contractor Registration Rev. 09/26/2017
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Contractor Registration Form (City of Dania Beach)

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Completed 14 July 2020

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