INFORMATION UPDATE
DATE: _______________
LICENSE NUMBER(S):____________________________________________________________________
CONTRACTOR'S NAME:__________________________________________________________________
HOME ADDRESS:_______________________________________________________________________
PHONE NUMBER: ____________________ FAX: ___________________ CELL: ____________________
EMAIL: _______________________________________________________________________________
BUSINESS NAME: ______________________________________________________________________
LEGAL ADDRESS: _______________________________________________________________________
MAIL ADDRESS: ________________________________________________________________________
DRIVERS LICENSE NUMBER: __________________________________
FLO
RIDA STATUTE 837.06 - FALSE OFFICIAL STATEMENTS. Whoever knowingly makes a false statement
in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty
of a misdemeanor of the second degree.
I HE
REBY CONFIRM THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST MY OF KNOWLEDGE.
______
_________________________________
Signature of License Holder
Pl
ease submit this form either in person, by fax (352)754-4416, or by email Bldg@HernandoCounty.us
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