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Electrician Contractor Registration Application/Renewal

2. 
3. License Type*

   1. New
   2. Renewal
5. Business Name*
6. Owner Name*
8. Business Website
9. Business Phone*
10. Alternate Phone
12. Primary Contact*
13. Email Address of Applicant*
15. Mailing Address*
16. Physical Address (If different from mailing)
18. City*
19. State*
20. Zip*
22. STATE-ISSUED LICESNE CREDENTIALS
    All permits shall require that any change of State-issued credentials for an active permit, a contractor registration, or master contractor be reported in writing by the permittee.
24. Master Electrician License*
25. State Electrician License*
26. State Electrical Contractor License Number*
28. Certificate of Insurance*

    Please include a current copy of your certificate of liability insurance naming Town of Eagle as Certificate Holder.

30. List Three Character References
32. Name*
33. Phone/Address*
35. Name*
36. Phone/Address*
38. Name*
39. Phone/Address*
41. Three Persons of Corporations you Have Done Work For
43. Name*
44. Phone/Address*
46. Name*
47. Phone/Address*
49. Name*
50. Phone/Address*
52. Have you Ever Defaulted on a Contract?*

    1. Yes
    2. No
53. Have you Ever Been Involved in a Lien Suit?*

    1. Yes
    2. No
54. Have you Ever Been Convicted of a Felony?*

    1. Yes
    2. No
55. Have you or your Business Ever Filed Bankruptcy?*

    1. Yes
    2. No
57. LICENSES ARE VALID FOR ONE CALENDAR YEAR: JANUARY 1ST THROUGH DECEMBER 31ST (No partial year credit)
59. Affirmation of Applicant *

    By Checking this box, I state under penalty of perjury in the second degree, as defined in 31-20-105, Colorado Revised Statutes, that the information contained above is true and correct to the best of my knowledge. I understand that providing false information is grounds for denial, suspension, or revocation of a license. Any person or entity who knowingly violates any provision of Eagle Municipal Code Chapter 5.13 or knowingly fails to performs an act by any provision of this Chapter, commits a Class A municipal offense.

    1. I agree with this Affirmation (required)
61. Payment Instructions

    Pay by Credit Card (Visa, MasterCard, Discover or e-check) through Community Core. Applicant will receive Account Set Up email from Community Core after form is submitted & processed. There is no fee for using this service. If you choose to pay by check, please make payable to the Town of Eagle. Checks can be mailed to PO Box 609, Eagle CO 81631 or dropped off at 200 Broadway. Please include the business name on your check to ensure accuracy.

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field