Jorgensen Registration 2014.tif CITY OF BLAIR FOR OFFICE USE ONLY
f � 4 218 S 16TH STREET
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BLAIR, NE 68008 Date Paid: / °� t-3
N Receipt t No: L
°,: (402) 426 e 4191 P
� FAX (402) 426 - 4195 Date Issued:
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Email: city ®fblair@ci.blair.ne.us BOND EXPIRES
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CONTRACTOR RE IT ATI / LICENSE RENEWAL
Please verify and correct
the companySbusiness
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: GENERAL
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 1/1/2014
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
L_1 Jorgensen, Gerald P. General Contractor 12/31/2013 $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 abo id vocation. I a e to conform strictly to the Ordinances of the City of Blair, Nebraska relative to said
vocation nd obey I order, red 1 ients and regulations of its lawful constituted authorities.
I-Autho d`Ylgna re Date
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