Matzen Registration 2011.tif FOR OFFICE USE ONLY
CITY OF BLAIR (
Date Paid:
218 S. 16 Street Receipt No:
Date Issued:
Blair, NE 68008 BOND EXPIRES: /
(402) 426 4191 FAX: (402) 426 4195 1 l �O
Email: ciWofblair@ci.blainne.us
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CONTRACTOR RE 1ST I /LICE SE RENEWAL
(Please type or print in ink - If you need more space, please attach additional sheets)
Application is for: Journeymen /Apprentice - $25.00 each
Business Name:
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Master's Name: c vc I Y L L
Business Address: c.� I �v� City: State: /"/,'� Zip:
Phone #: Mobile #:
Please List all employees that you wish to register and check the appropriate boxes.
Name Plumber Heater Electrician Apprentice Journeyman
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All information contained in this application is true and correct. 1 will notify the City of Blair of any changes in the information
reported on or with this application form within ] 5 days of the change.
I hereby make application to the Licensing Board of Blair, Nebraska and certify that 1 am competent and experienced to
engage in above said vocation. 1 agree to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocation and obey all order, requirements and regulations of its lawful constituted authorities. This certification applies to the
original license and /or registration and any renewals thereof.
Authorized S' nature /' Date