Application for a Certificate of Competency

1 Application for a Certificate of Competency CONSTRUCTION INDUSTRY LICENSING BOARD OF PALM BEACH COUNTY (Contractors Certification Division PZ&B) 2300 N Jog Road, 2nd Floor, Suite 2W-61, West Palm Beach, FL 33411 Phone: (561) 233-5525 Thank you for your interest in applying for a Certificate of Competency . This Application is for an applicant that is applying by Examination or via County Reciprocity within Florida; the fee for Application is $ This Application package includes the following: Application - Sections 1 thru 9 (pages 1-7) Step by Step Application Instructions (pages 1-8) Required Forms 1.

2 Corporate Officer Affidavit (Optional) 2. Financial Statement 3. Applicants Employment History 4. Affidavit of Construction Experience Informational References 1. Examination Information for Contractors Certification Licenses 2. Classification & Construction Trade Requirements 3. Background Fingerprint Service Providers 4. Financial Responsibility & Stability (Optional) 5. 2019 Board Meeting Schedule Certificate OF Competency Application Page 1 of 7 Certificate of Competency Application Rev.

3 7/3/19 Please type or print all information clearly; complete all sections of the Application in its entirety in blue or black ink. Anything that does not apply fill in with N/A. Additional information for each section outlined in the step-by-step Application instructions. Section 2 Personal Information Full Legal Name First: Middle: Last: Birth Date: (mm/dd/yyyy) Gender: Male Female Citizenship Status Social Security #: Driver s License #: Issuing State: Place of Birth: Citizen of the United States?

4 (if no, provide documentation as to residency status) Yes No Photograph Received Date (Attach photo in this area) (Office Use Only) Application Number: (Office Use Only) Section 1 Application Information Application Type (Check One): a)by Examination or b) by Reciprocity from _____County Classification / Trade (Check One): a)General b)Building c)Residential d)Electrical e)Plumbing f) HARV or g)Specialty (specify trade):_____ Certificate Status: Certificate to be issued: Active or Inactive Certificate OF Competency Application Page 2 of 7 Certificate of Competency Application Rev.

5 7/3/19 Section 3 Business Information Company Information Company s Full Legal Name: INC/CORP/LLC d/b/a (if applicable): Business Address: (No PO Box) Suite: Business Phone: City: State: Zip Code: Business Fax: Date Company Established: Federal Employee Identification Number:(FEIN) Business Questionnaire a.

6 I am qualifying for a (choose one): Partnership/Corporation or LLC Sole Proprietorship b. Will you be supervising employees of this company (choose one): Yes (c) No (d) c. If yes, please provide the number of employees and their duties. d. If No, please explain: Residential Address Street Address: (No PO Box) City: State: Zip code: Contact Information Primary Phone Number: Primary E-mail address: Certificate OF Competency Application Page 3 of 7 Certificate of Competency Application Rev.

7 7/3/19 e. Please describe your supervision duty under your trade, only if you answered yes on (c): Current Construction Licenses (copies required, if you answered g) 1. License #: County/State: Date Issued: (M/Y) 2. License #: County/State: Date Issued: (M/Y) 3. License #: County/State: Date Issued: (M/Y) 4. License #: County/State: Date Issued: (M/Y) Complete this section if you are qualifying a Corporation or an LLC: Title ( ) Officer or Member Name Home Address, City, State, Zip Contact number Corporate Officer Affidavit Form (Optional) Complete form if you have filled out section with information other than the applicants.

8 (Intentionally left blank) Certificate OF Competency Application Page 4 of 7 Certificate of Competency Application Rev. 7/3/19 Section 4 Criminal Background Have you applied for you live scan fingerprints? Yes No Have you ever been convicted or found guilty of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a crime in any jurisdiction? This question applies to any criminal violation of the laws of any municipality, county, state, or federal including felony, misdemeanor and traffic offenses (but not to include parking, speeding, inspection, or traffic signal violations) without regard to whether you were placed on probation, had adjudication withheld, were paroled, or pardoned.

9 If you intend to answer no because you believe your records are expunged or sealed by court order pursuant to section or of Florida Statute or the applicable law of another state, proof of expungement may need to be provided if the expunged records appear on a background check. Your answer to this question will be checked against local, state, and federal records. Failure to answer this question accurately may result in the denial of your Application . Yes No Have you ever had any construction related trade Certificate of Competency license denied, or is there now pending a proceeding or investigation to deny such an Application from any construction related Certificate of Competency licensee authority (Federal, State, County or municipal) within the United States?

10 Yes No Has any license, registration, or permit to practice any regulated profession, occupation, vocation, or business been revoked, annulled, suspended, relinquished, surrendered, or otherwise disciplined in Florida or in any other jurisdiction, or is any such proceeding or investigation now pending? Yes No Have you ever been issued a Notice of Non-Compliance, Notice of Violation, a Citation, or received any disciplinary action, construction related (including a fine(s) or reprimand) by any State, County or Municipal Authority?