Contractor Registration Form

Name of Business*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email*
Owner's Name*
First Last
Phone*
Fax
Email*
General Contractor (if applicable)
Job Site*
REQUIREMENTS & FEES*
- General Contractor-$100.00
- Contractors & Subcontractors (per trade)-$50.00
ALL GENERAL CONTRACTORS MUST SUBMIT: 1) A signed original $10,000.00 Surety Bond. 2) Certificate of Insurance w/General Liability of $500,000/Auto $500.000/Workers Comp $500.000 All Sub Contractors Must Submit: Exception Plumbers and Roofers 1) A signed original $5000.00 Surety Bond. 2) Certificate of Insurance w/General Liability of $500.000/Auto $500.000/Workers Comp $500.000
List Trades
Surety Bond Expiration*
Date Format: MM slash DD slash YYYY
Certificate of Insurance Expiration*
Date Format: MM slash DD slash YYYY
State of Illinois Roofing License Expiration*
Date Format: MM slash DD slash YYYY
State of Illinois Plumbing License Expiration*
Date Format: MM slash DD slash YYYY
I HEREBY DECLARE THAT ALL OF THE ABOVE INFORMATION GIVEN IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I AGREE TO COMPLY WITH ALL VILLAGE AND STATE CODES, ORDINANCES AND LAWS NOW IN FORCE AND ANY OTHERS THAT MAY BE ENACTED DURING THE DURATION OF REQUESTED LICENSE. I FURTHER UNDERSTAND THAT DURING THIS LICENSING PERIOD, SHOULD ANY OF THE REQUIRED INSURANCE/LICENSING DOCUMENTS EXPIRE, THIS LICENSE BECOMES NULL AND VOID.
Signature