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2. Contact Information
4. Name of Firm:*
6. Street Address:*
8. City:*
9. State:*
11. Zip:*
12. Phone:*
14. Fax:
15. Cell:
17. Pager:
18. Email:
20. Contact Name:*
22. Business Information
24. Type of Business:*
    -- Select One --BlankElectricalGeneralLandscapePlumberRoofer
26. Business Owner's Name:*
28. Insurance Agent:*
30. Insurance Agent Phone:*
32. No license shall become effective until such date as the required certificate of insurance has been submitted and is on file with the Village.
34. Upload Certificate of Insurance:
36. Upload License:
38. By submitting this form, you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) by signing in this alternate manner, you agree that your “electronic signature” is valid and binding upon you to the same force and effect as a handwritten signature.
40. For Village Use Only
42. License No:
44. Expiration Date:
46. Date Issued:
48. Fee Received:
50. Approved By:
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field