Contractor Registration

Contractor Registration
Company Name*
Is your business based in Coral Springs*

YesNo
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Business Phone*
Business Fax
Business E-mail *
example@example.com
Qualifier Information
Name*

First NameLast Name
Phone*
Cell Phone
Select one that applies to you*

State LicenseCounty Certificate
State License
State License #*
Expiration Date*

MonthDayYear
State License Document*

Upload copy of State License Document - 25MB size - pdf, jpg, png
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County Certificate
County Certificate #*
Expiration Date*

MonthDayYear
Classification*
County Certificate Document*

Upload copy of County Certificate Document - 25MB size - pdf, jpg, png
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Business Tax

This is required only if your business is based in Coral Springs.
Business Tax Receipt*
Business Tax Receipt Document*

Upload copy of Business Tax Receipt Document - 25MB size - pdf, jpg, png
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Workers Comp Insurance Information
Please select one*

Workers Comp InsuranceWorkers Comp Exempt
Company Name*
Policy Number*
Expiration Date*

MonthDayYear
Workers Comp. Insurance Company*

Copy of Workers Comp. Insurance Company Document - 25MB size - pdf, jpg, png
Cancelof
Expiration Date*

MonthDayYear
Workers Comp. Exempt Letter *

Copy of Workers Comp. Exempt Document - 25MB size - pdf, jpg, png
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General Liability Insurance Information
Company Name*
Policy Number*
Expiration Date*

MonthDayYear
General Liability Insurance Company *

Copy of General Liability Insurance Company Document - 25MB size - pdf, jpg, png
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Emergency Contact
Name*

First NameLast Name
Emergency Phone*
Should be Empty:

Contractor Registration

Qualifier Information

State License

County Certificate

Business Tax

Workers Comp Insurance Information

General Liability Insurance Information

Emergency Contact