Contractor Registration Form – Welcome to Whitehouse, Ohio

Date

Registration Year

Company Name*

Contact Name*

First Last

Title*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Email

Type of Work*

Please check all that apply

Work Category*

Please select all that apply

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?*

Workers' Comp Certificate*

This form is required

Workers' Comp Certificate Copy*

Please provide a copy of your workers' comp certificate.

State of Ohio License*

This form is required

State of Ohio License Certificate*

Please attach a copy of your State of Ohio registration license

Proof of Liability Insurance*

This form is required

Proof of Liability Insurance Form*

Please attach a copy of your proof of liability insurance.

Do you have subcontractors?*

Each of your subcontractors must also fill out a separate Contractor Registration Form.*

How will you remit the $50 registration fee?*

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.

Your Name & Title*