MidlandU Registration 2012.tif I
CITY OF BLAIR FOR OFFICE USE ONLY
� 218 S 16TH STREET
i BLAIR, NE 68008 Date Paid:
wg (402) 426 - 4191 Receipt No:
FAX (402) 426 - 4195
Date Issued:
is Email: cityofblair @ci .blair.ne.us BOND EXPIRES`
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Please verify and correct
Midland Trenching the company /business
g in formation listed here:
5240 Co Rd 140 1
Ft. Calhoun, NE 68023
i
Phone numbers on record: j
Type: Phone Number: Type: Phone Number:
Office 402 573 5018
Mobile 402 6812015
Email Address:
Type of Business: _ � , iNS
Please submit new reciprocating license ( ?orthose which have expired:
Name Reciprocating License Expires
Steve Kimberling Drainlayer Reciprocating 12/31/2010
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Steve Kimberling Drainlayer Bond 4/20/2012
Place a check in the box next to the licenses you wish to renew:
RenewV Name License / Registration Expires Amount
Steve Kimberling Drainlayer 12/31/2011 $60
Please list an additional license or registrations:
Y g
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
vo tion and obey I ord r, re irements and regulations of its lawful constituted authorities.
Authorized Signature Date
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