Jorgensen Registration 2013.tif CITY OF BLAIR FOR OFFICE USE ONLY
218 S 16TH STREET
BLAIR, NE 68008 Date Paid:
Receipt . (402) 426 - 4191 t No: p
�* FAX (402) 426 - 4195 Date Issued: !
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:
Type: Phone Number: Type: Phone Number:
Office 402 426 4440
Mobile 402 533 3165
Email Address:
Type of Business: G ENERAL
Please submit new certificates or bond renewals for those which have expired:
Name Certificate of Liability or Bond Expires
Jorgensen, Gerald P. General Certificate of Liability 1/1/2013
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
E� Jorgensen, Gerald P. General Contractor 12/31/2012 $60
Please list any additional license or registrations:
Name License / Registration Amount
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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 o e II order, requ' a ents and regulations of its lawful constituted authorities.
~'� �-,
Authorize igna re Date