Jorgensen Registration 2012.tif �'.. CITY OF RLAIR FOR OFFICE USE ONLY
218 S 16TH STREET t
BLAIR, NE 68008 Date Paid:
�a
k
( )
402 426 - 4191 Receipt No:
FAX (402) 426 - 4195 Date Issued:
` )s0 � "a Email: cityofblair @ci.blair.ne.us BOND EXPIRES
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
the company /business
Jorgensen Contracting, Inc. information listed here:
530 Front St
Blair, NE 68008
Phone numbers on record: j
Type: Phone Number: Type: Phone Number:
I
Office 402 426 4440
Mobile 402 533 3165
Email Address:
I
Type of Business: GENERAL
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Gerald P. Jorgensen General Certificate of Liability 1/1/2012
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
❑ Gerald P. Jorgensen General Contractor 12/31/2011 $60
Please list any additional license or registrations:
Name License / Registration Amount
--------------------------------------------------------------------------------------------------------------------------------------------
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 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 and :obey all or r, requirements and regulations of its lawful constituted authorities.
t,
Authorized Signature Date