HERNANDO COUNTY STATE CERTIFIED REGISTRATION FORM
DA
TE: ______/_______/______ PLEASE TYPE OR PRINT NEATLY
BUS
INESS NAME AND QUALIFIER'S NAME AS IT APPEARS ON STATE LICENSE:
_______________________________________________________________________________
Ho
me Address: ______________________________________________________________________
_
______________________________________________________________________
City State Zip Code
Bus
iness Address:_____________________________________________________________________________
___
____________________________________________________________________
City State Zip Code
Bus
iness Phone: ______________________CELL______________________FAX___________________________
County:_______________________________________________________________________________________
Drivers License Number__________________________________________________________________________
E-MAIL ADDRESS:_____________________________________________________________________________
PL
EASE FURNISH WITH THIS REGISTRATION FORM THE FOLLOWING DOCUMENTS:
**FAXED COPIES WILL NOT BE ACCEPTED**
1. Current copy of STATE CERTIFIED LICENSE.
2. Certificate
of Liability Insurance and Workers Compensation with Hernando County Building Division, 789
Providence Blvd., Brooksville, FL 34601 as the Certificate Holder.
CERTIFICATES MUST BE MAILED FROM THE INSURANCE CO. (If faxed, must be from insurance co. and
followed up by mail).
3. Copy of current DRIVER’S LICENSE or other identification with photo and signature. COLOR PLEASE
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____________________________
Subscribed and affirmed before me this _______day of _____________________,________
by____________________________________who is(___)personally known to me or who(___)has produced
__________________as identification.
_____________________________________ _____________________________
Signature of Notary Public Commission Number Seal
Statecert 5-17 **FAXED COPIES WILL NOT BE ACCEPTED**
