STATE REGISTERED CONTRACTOR

$50.00 FEE DATE:

TYPE OF CONTRACTOR:

BUSINESS NAME:

QUALIFIER NAME:

MAILING ADDRESS:

PHYSICAL ADDRESS:

QUALIFIER DRIVER’S LICENSE STATE: DL #:

QUALIFIER D.O.B.: BUSINESS E-MAIL:

BUSINESS PHONE: BUSINESS FAX:

BUSINESS MOBILE:

QUALIFER SIGNATURE: _________________________________________________

The following is REQUIRED to be submitted with this application. Incomplete applications not accepted.

Copy of Florida State Registration & Florida State Qualified Business License.

Proof of Exam:

•

Mailed directly from Sponsor or Hand-delivered in an unopened sealed & stamped envelope from the sponsor

•

Faxed from Sponsor or Emailed directly from Sponsor

Copy of Business Tax Receipt

Certificate of Insurance for:

•

General Liability

•

Worker’s Compensation or State of Florida - Worker’s Compensation Exemption Certification.

Certificate Holder: Indian River County Building Department, 1801 27

Street, Vero Beach, FL 32960

•

Longshore Insurance if you are an employer with employees covered under the Longshore Act

Copy of Qualifiers Valid Driver’s License.

Payment in the amount of $50.00. (Cash, Check, Credit Card, or Credit Card Authorization Form by FAX)

I hereby agree to keep the required insurance in force, and to procure a City of Vero Beach or Indian River County Local Business

Tax Receipt prior to opening a place of business within these jurisdictions.

Acknowledgement for Person in an Individual

Capacity

Acknowledgement for Person in a

Representative Capacity

State of Florida, County of _____________________

The foregoing instrument was acknowledged before me

means of  physical presence or  online notarization this

_______ day of _________, 20_____

By _______________________________________

who is  personally known or  produced identification

Type of ID Produced _____________________________

Printed Name of Notary ___________________________

Signature of Notary ______________________________

Notary Seal

State of Florida, County of _____________________

The foregoing instrument was acknowledged before by

means of  physical presence or  online notarization this

______ day of _______, 20 ______, by

____________________________ (Name of Person) as

___________________________ ( Explain

Representative Capacity) for ____________________

(Name of Party on Behalf of Whom Instrument was

Executed).

who is  personally known or  produced identification

Type of ID Produced _____________________________

Printed Name of Notary ___________________________

Signature of Notary ______________________________

Notary Seal

APPLICATION FOR REGISTRATION INDIAN RIVER COUNTY/CITY OF VERO BEACH

STATE REGISTERED CONTRACTOR

BUILDING DIVISION

CONTRACTOR LICENSING DEPARTMENT

772-226-1960

FAX #: 772-770-5333

INDIAN RIVER COUNTY/

CITY OF VERO BEACH

COMPETENCY CARD PROCEDURES

STATE REGISTERED APPLICANTS:

1. Complete application form for State Registered Applicants.

2. Submit a copy of current Florida State Registration & Qualified Business License (Unless registered as an Individual)

3. Submit original LETTER OF RECIPROCITY for Florida Block & Associates exam results (minimum passing

grade = 70%) by mail, fax or hand carried in a sealed envelope from your sponsor.

4. Provide Certificate of Insurance for:

• General Liability

• Worker’s Compensation

• Longshore Insurance if you are an employer with employees covered under the Longshore Act

Made out to: Indian River County Building Department, 1801 27

Street, Vero Beach, FL 32960

Note: If you’re exempt from Worker’s Compensation Insurance, please provide proof of exemption.

5. Submit copy of current business tax receipt (municipality of business).

6. Submit copy of Valid Driver’s License.

7. Submit a $50 competency card fee. NOTE: Fee is annual; competency cards expire July 31

THESE DOCUMENTS MAY BE EMAILED, MAILED, DELIVERED OR FAXED. IF FAXED, PAYMENT CAN BE MADE

WITH CHARGE CARD. PLEASE VISIT WWW.INDIANRIVER.GOV AND VISIT THE BUILDING DIVISION PAGE TO

DOWNLOAD THE CREDIT CARD FORM.

To submit a completed application (pdf format) or for further information, contact the Contractor Licensing

Department by email: [email protected]

R E G I S T E R E D

CUSTOMERS WILL BE RESPONSIBLE FOR THE SERVICE CHARGE FOR CREDIT AND DEBIT CARD TRANSACTIONS

(2.5% PER TRANSACTION WITH A $2 MINIMUM)

Board of County Commissioners

Indian River County Building Division

1801 27

Street, Vero Beach, Florida 32960-3365

Telephone (772) 226-1260

Please complete and fax back to (772) 770-5333

***Note: All documents submitted via email are subject to public

records request. This form should only be faxed in***

CREDIT CARD AUTHORIZATION

Date: _________________________

Company Name: _________________________________________________________

TYPE OF PAYMENT:

( ) Re-inspection Fees (Permit # _______________________________________)

( ) Archive Request Information

( ) Permit Application

( ) Competency Card: __________________________________________________

Company Name

CARD: ( ) Visa ( ) Master Card ( ) Discover Card ( ) AMEX

Card Holder Name: ________________________________________________

Billing Address: ________________________________________________

City: ______________ State: __________ ZIP: _____________________

Card Number: ________________________________________________

Expiration Date: ___________ CCV: __________________________

Amount Charged: $___________________________

Card Holder/Company Fax Number: _________________________________________

Card Holder/Company Telephone Number: ____________________________________

I authorize the Indian River County Building Division to charge the above amount to the

credit card number provided.

_________________________________

Authorized Signature

_________________________________ ______________________________

Authorized Printed Name Title