Name of Applicant*

DBA / Company Name*

Address*

City*

State*

Zip*

Telephone Number*

Fax Number*

Cell Phone Number*

Contractor Email*

LIABILITY INSURANCE REQUIRED:

Insurance Certification Attached*

YES

NO

I hereby make application for registration of a:

Building Contractor Sign Contractor Plumbing Contractor Sewer-Excavating Contractor HVAC Contractor Electrical Contractor

Low Voltage Contractor Roofing Contractor Concrete Contractor Fire Alarm Fencing Contractor Other Contractor (Flooring, Painting, Glass, etc.)

***** PLEASE NOTE: All Plumbing applicants MUST provide a copy of their Indiana State Plumbing Contractor’s License and ALL Electrical and HVAC applicants MUST apply to the Michigan City Licensing Board for approval BEFORE registering.

New Applicants:
$150.00 ------

Renewals:
$100.00 ------