Jorgensen Registration 2011.tif I
FOR OFFICE USE ONLY
CITY OF BLAIR
20
218 S. 16TH STREET Date Paid: �I `1 ( U
BLAIR NE 68008 p 2-71-77 � Recei No:
(402) 426 -4191
FAX (402) 426 -4195 Date Issued: D
a '^ B o a email: CityofBlair @huntel.net BOND EXPIRES:
promise o (Continued)
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Verify the following information:
Business Name: Jorgensen Contracting, Inc.
Address Gerald P. Jorgensen
530 Front Street
Blair, NE 68008
Phone # 402 - 426 -4 440
Mobile #
Number of Employees: Journeymen: Apprentices:
Type of Business: General Contractor
Other Licenses Held:
Insured? Yes Worker's Compensation? Yes
i
i
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registrat A mount
0 Gerald P. Jorgensen General Contractor 01/01/2011 $60.00
List additional license / registrations:
Name License / Registration Amount
i
I
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 the change.
I hereby make application to the Licensing Board of Blair, Nebraska and certify that I am competent and
experienced to engage in above said vocation. I agree to conform strictly to the Ordinances of the City of
Blair, Nebraska relative to said vocation d all order, requirements and regulations of its lawful
constituted authorities.
�Authorized Si re Date
i