CERTIFICATE OF COMPETENCY APPLICATION
“Delivering Exceptional Service”
Building Construction Division
Licensing Section
18400 Murdock Circle
Port Charlotte FL 33948
Phone: 941.743.1201
Fax: 941.743.4907
www.CharlotteCountyFL.gov
Received Date: __________________
Receipted By: ___________________
POS #.: _____________ $ __________
Certificate of Competency Application (Created January 2007 | Revised February 2020 DJ) Page 2 of 2
Applicant Authorization & Signature
I hereby authorize investigation of all statements contained in this application. I understand that misrepresentation or
omission of facts is cause for disciplinary action by the Construction Industry Licensing Board. I also authorize release of
Sheriff and Police records to the Licensing Section of the Building Construction Division. I hereby release you, your
organization or others from any liability for damage which may result from furnishing the information requested herein. I
also agree to familiarize myself with and abide by all local ordinances, state regulations, and the Florida Building Code
governing all restrictions about the license I have been issued.
_______________________________________________ ______________________________________________
Signature of Applicant (witnessed by a Notary) Printed Name of Applicant
State of ____________________, County of ________________________
This instrument was acknowledged before me
this _______ day of ________________, 20 _____ by
_________________________________________________ (name of person making statement), who is _____ personally
known to me _____ or has produced _____________________________ as identification and _____ who did or _____ did
not, take an oath.
Notary’s Signature ______________________________ Notary’s Printed/Stamped Name __________________________
Commission Number ____________________
Credit Report Business Name:
Fictitious Name Registration:
Articles of Incorporation:
Minutes of Meeting Listing Officers:
Resolution of Authorization
General Liability Policy:
Worker’s Compensation Policy
Worker’s Compensation Exemption:
Application Type (check or circle): New _____ Reactivate Inactive: _____ Reactivate Expired: _____ Name Change: _____
Application is hereby (check or circle): _____APPROVED _____ DISAPPROVED _____
Staff Signature: _________________________________ Title: __________________________________ Date: ______________________
Reason for Disapproval (check or circle): _____ LACKS EXPERIENCE _____ UNFAVORABLE CREDIT _____ OTHER
Explanation of Other: ______________________________________________________________________________________________
________________________________________________________________________________________________________________
APPLICANT:
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