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✕
Contractor Registration Form
Date
Registration Year
Company Name
*
Contact Name
*
First
Last
Title
*
Address
*
Street Address
Address Line 2
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State
ZIP Code
Phone
*
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Type of Work
*
Please check all that apply
Commercial
Residential
Industrial
Work Category
*
Please select all that apply
Accessory Structures
Cabinet Builder
Concrete/Masonry
Electrical
Fencing
Fire Suppression
Foundations
General Contracting
Gutters
Hauling
Home Builder
HVAC
Landscaping
Lawn Sprinklers
Pools
Plumbing
Refrigeration
Remodeling
Repairs/Waterproofing
Roofing
Sewer
Sidewalk
Siding
Sign Builder
Steamfitter
Windows
How many years' experience do you have doing this type of work?
*
How long has your company been in business?
*
How long has your company been under its current ownership?
*
Do you have employees?
*
Yes
No
Workers' Comp Certificate
*
This form is required
I can attach it now.
I will fax it to 419-877-5635 within 2 business days.
I will email it to jherman@whitehouseoh.gov within 2 business days.
Workers' Comp Certificate Copy
*
Please provide a copy of your workers' comp certificate.
State of Ohio License
*
This form is required
I can attach it now.
I will fax it to 419-877-5635 within 2 business days.
I will email it to jherman@whitehouseoh.gov within 2 business days.
State of Ohio License Certificate
*
Please attach a copy of your State of Ohio registration license
Proof of Liability Insurance
*
This form is required
I can attach it now.
I will fax it to 419-877-5635 within 2 business days.
I will email to jherman@whitehouseoh.gov within 2 business days.
Proof of Liability Insurance Form
*
Please attach a copy of your proof of liability insurance.
Do you have subcontractors?
*
Yes
No
Each of your subcontractors must also fill out a separate Contractor Registration Form.
*
I acknowledge
I do not acknowledge
How will you remit the $50 registration fee?
*
Drop off
Mail In
Online (fees apply)
Signature Acknowledgement
*
I acknowledge that I am authorized by my company's owner, president, CEO, or other designated authority to submit this form on our company's behalf.
I acknowledge
I do not acknowledge
Your Name & Title
*