Jorgensen Registration 2016.tifCITY OF BLAIR
218 S 16TH STREET
BLAIR, NE 68008
(402) 426 - 4191
FAX (402) 426 - 4195
Email: cityofblair@ci.blair.ne.us
FOR OFFICE USE ONLY
Date Paid: �z Z // ..µ
Receipt No: -
Date Issued:
BOND EXPIRES'
CONTRACTOR REGISTRATION / LICENSE RENEWAL
Jorgensen Contracting, Inc.
530 Front St
Blair, NE 68008
Phone numbers on record:
Type: Phone Number: Type: Phone Number:
Please verify and correct
the company/business
information listed here:
Office 402 426 4440
Mobile 402 533 3165 PLEASE SUBMIT A COPY OF YOUR
Email Address: CURRENT NEBRASKA DEPARTMENT OF
LABOR REGISTRATION
Type of Business: GENERAL YOUR CERTIFICATE IOF LIABILITY
INSURANCE IS EXPIRED OR ABOUT TO
Please submit new certificates or bond renewals for those which have expired: EXPIRE. PLEASE SUBMIT ANEW COPY
Name Certificate of Liability or Bond Expires WITH YOUR RENEWAL.
Jorgensen, Gerald P. General Certificate of Liability 1/1/2016
Place a check in the box next to the licenses you wish to renew:
Renew? Name License / Registration Expires Amount
,L-;� Jorgensen, Gerald P. General Contractor 12/31/2015 $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 an a all order, requirements and regulations of its lawful constituted authorities.
Authori d Si ure Date
4WNEBRASKA
DEPARTMENT OF LABOR
www. do 1. n e b rask a. gov
Department of Labor
Labor Law / Contractor Registration
550 South 16th Street, 3rd Floor
Lincoln, NE 68508
(402) 471 - 2239
Registered Contractors and Subcontractors Locator
Contractor/Subcontractor Name:
Address:
City:
State:
Zip:
Telephone:
Certificate Number:
Certificate Expiration:
Contractor Option:
JORGENSEN CONTRACTING, INC.
530 FRONT ST
BLAIR
NE
68008
(402)426-4440
23004
01/01/2017
2