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Contractors Must Submit the Following Items With the (Village of Wellington)

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12300 West Forest Hill Boulevard • Wellington, Florida 33414 • (561) 753-2430 • Fax (561) 791-4045
www.wellingtonfl.gov
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
AGREATHOMETOWN
Great Neighborhoods Great Schools GreatParks LetUsShowYou!
Contractors Must Submit the Following Items
With the Registration Application
Email to: BuildingDocs@WellingtonFL.gov
Palm Beach County/County-wide Business Tax Receipt for the current fiscal year.
A copy of the Qualifiers Driver’s License or photo identification.
Palm Beach County Certificate of Competency and/or State of Florida Department of Business and
Professional Regulation License.
Certificate of Liability Insurance, naming W ellington as Certificate Holder.
Certificate of Workers Compensation Insurance or Exemption Certificate.
Certified State License holders based in another County must provide a copy of their Business Tax
Receipt for the Coun
ty in which they are based.
AGREATHOMETOWN
Great Neighborhoods • Great Schools • GreatParks LetUsShowYou!
Receipt # Process By: Issued By: Date Issued:
Company Name
Address
Street
City State Zip
Mailing
Address
(if
different) Street City State Zip
Business Phone Cell Phone FAX
Email Address
Qualifiers Name Phone
Home
Address
Street
Driver’s License #
City
Contractor’s License #
State Zip
Nature of Business
_
Owner’s Name
Home
Address
Street
City State Zip
FE
IN
o
r
So
c
ial S
ec
uri
ty N
umb
er
Qualifier Signature Date
•
(Type of ID)
Notary Signature
Notary Public, State of
• • •
Contractor Registration Application
COMPANY INFORMATION
QUALIFYING AGENT
BUSINESS OWNER – If Different From Qualifier
Pursuant to FS 205.0535(5) No Business Tax shall be issued unless the FEIN number or SSN number is obtained from the person to be taxed.
If a FEIN is not available the applicant must provide the Social Security number for the person being taxed pursuant to section FS 119.071(5)
I hereby declare this application has been examined by me as of this date and to the best of my knowledge and
belief is true and accurate.
NOT
ARY CERTIFICATE
STATE OF FLORIDA
PALM BEACH COUNTY
The foregoing instrument was acknowledged before me this day of , 20,
by Whom is personally known to me or has produced
as identification.
12300 West Forest Hill Boulevard Wellington, Florida 33414 (561) 753-2430 Fax (561) 791-4045
www.wellingtonfl.gov
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Contractors Must Submit the Following Items With the (Village of Wellington)

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Completed 17 July 2020

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