Jorgensen Registration 2023CITY OF BLAIR
218 S 16th Street
Blair, NE 68008
(402) 426-4191
Fax (402) 426-4195
Email: building@blairnebraska.org
JORGENSEN CONTRACTING INC
530 FRONT ST
BLAIR NE 68008
Type of Business: CONT RACTOR OR LICENSE
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FOR OFFICE USE ONLY
Date Paid: 1
Receipt No: y
Date Issues: 72 1
BOND EXPIRES:
Please verify and correct the
company / business
Information listed here:
Type:
Phone Number: Type: Phone Number:
Work
(402)426-4440 Fax
Cell
(402)533-3165
Email Address:
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Please submit a current reciprocating license or those which will or have expired:
Name: Reciprocating License: Expires:
Ploncp .vuhmit "Pw rprti{irntps nr hond renewals and ND01, for those which will or have expired:
Name:
Certificate of Liability or Bond:
Expires:
JORGENSEN CONTRACTING INC
GENERAL
1/01/2023
JORGENSEN CONTRACTING INC
NDOL
1/01/2023
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Renew? Name: License / Registration: Expires: Amount:
JORGENSEN CONTRACTING INC CONTRACTOR LICENSE 1/01/2023 60.00
Pay this amount: 60.00
Please list any additional licenses or registrations:
Name: I License/ Re istration: Amount:
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and
experienced to engage in the above said vocation.
I agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said vocation and obey all
orders, requirements and regulations of its lawful constituted authorities.
I also certify that all information contained in this application is true and correct. I will notify the City of Blair
of any changes in the information reported on or with this application form within 15 days of any change.
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