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2. _________________________________________
   Date
3. _________________________________________
   Print Name of Qualifier
5. _________________________________________
   Qualifier's Company Name
6. _________________________________________
   Email
8. _________________________________________
   Company Address
9. _________________________________________
   Qualifier's License #
11. SIGNATURE OF CERTIFIED CONTRACTOR MUST BE NOTARIZED. THE FOLLOWING INDIVIDUALS FROM THE ABOVE FIRM ARE AUTHORIZED TO SIGN PERMITS FOR MY COMPANY IN THE CITY OF OLDSMAR:
13. _________________________________________
    Print Individual Name
14. _________________________________________
    Sign Individual Name
16. _________________________________________
    Print Individual Name
17. _________________________________________
    Sign Individual Name
19. _________________________________________
    Print Individual Name
20. _________________________________________
    Sign Individual Name
22. Authorization for the above individuals to sign for permits for my company will remain in effect until further notification from this company is provided to The City of Oldsmar. I am aware that if any changes are made by my company regarding the above information, it is my responsibility to notify The City of Oldsmar.
    Signature of Certified Contractor ____________________________________________
24. STATE OF FLORIDA
    COUNTY OF _______________________________
26. Sworn to and subscribed before me this ___________ day of _________________, 20______.
    By _______________________________________.
28. Notary Public, State of Florida (Print, type or stamp name)
    ____________________________________________
29. Seal:
31. Identification

    1. Personally known

    1. Produced Identification
32. _________________________________________
    Type of identification produced: Include ID #
Leave This Blank:


33. Print Only

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