Annual Contractor Registration Application

Contractor Category:

Demolition

Electrical

Mechanical

Plumbing

Fire Protection

General/Roofing

General (No Roofing)

Other

Company Information

Company Name:

Address:

City/State/Zip:

Business Phone:

Business Fax:

E-Mail:

Federal Tax ID #

State Tax ID #

Owner Information

Owner Name:

Owner Address:

City/State/Zip:

Owner Cell:

Form of Ownership:

Primary Contact

Contact Person:

Contact Cell:

Further Requirements

Name:

Date:

Certificate of Insurance to he Village of Milan in the amount of $100,000 property damage and $300,000 personal injury per occurrence.
$10,000 continuous license/permit bond on Village of Milan form.

By typing my name below, I certify that all information in this statement, and all information furnished in support of the statement is true and complete to the best of my knowledge and belief. Failure to comply with the conditions of this registration will result in revocation of the registration and cancellation of all active permits.

By typing my name below, I certify that I presently have no employees and will not hire any employee(s) to perform work in the Village of Milan during the duration of this registration unless I obtain workman compensation insurance and provide proof of such insurance to the Village of Milan.

Name:

Date: