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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.

    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

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
    Once you submit this form, you will be given the option to pay by credit card (Visa MasterCard and Discover or e-check), there is no fee for using this service. If you choose to pay in person or by mail, please mail a check made payable to the Town of Eagle PO BOx 609, Eagle CO 81631 or drop off at 200 Broadway. Please include the business name on your check to ensure accuracy.

    Once you submit this form, you will be given the option to pay by credit card (Visa MasterCard and Discover or e-check), there is no fee for using this service. If you choose to pay in person or by mail, please mail a check made payable to the Town of Eagle PO BOx 609, Eagle CO 81631 or drop off at 200 Broadway. Please include the business name on your check to ensure accuracy.

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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

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