Free 12012 12-07.xft - North Dakota

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CONTRACTOR LICENSE APPLICATION
SECRETARY OF STATE
SFN 12012 (12-07) Instructions: 1. Contractors working on any project where the cost, value, or price per job or contract exceeds $2,000.00 must hold a North Dakota Contractors License. 2. As stated in North Dakota Century Code, Chapter 43-07-07, the contractor's license class and fee are based on how much the cost, value, or price is per job. The license class and fee are listed below. Make checks payable to the Secretary of State. Credit cards also accepted.

ID # WO # License # Issued By

Check Appropriate Class of License
CLASS Class A License Class B License Class C License Class D License REQUIRED FOR no limitation on the value of any single contract any contract up to any contract up to any contract up to $250,000 $120,000 $ 50,000 FEE $300.00 $200.00 $150.00 $ 50.00

Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone 701-328-3665 Toll Free 800-352-0867 Ext 8-3665 Fax 701-328-1690 Web Page: www.state.nd.us/sec
Business Telephone #

3. The business name as registered in North Dakota: Business Name of Applicant Complete Mailing Address E-Mail Address City Web Address

State

Zip Code

4. If the business is a GENERAL PARTNERSHIP, all partners must be listed including full name, address, city, state, zip code, and Social Security or Federal ID number of each partner. If adequate space is not provided to list all general partners, attach an additional sheet listing all others. If the partnership uses a fictitious name, the fictitious name must be registered with the Business Division (701-328-4284). If the business is a LIMITED LIABILITY PARTNERSHIP, all managing partners must be listed including full name, address, city, state, zip code, and Social Security or Federal ID number of each managing partner. If adequate space is not provided to list all managing partners, attach an additional sheet listing all others. The limited liability partnership must be registered with the Business Division (701-328-4284). If the business is a CORPORATION or LIMITED LIABILITY COMPANY it must be registered with the Business Division (701-328-4284) by filing either Articles of Incorporation or Articles of Organization if a domestic organization, or Certificate of Authority if a foreign (out-of-state) organization. If the corporation or limited liability company uses a trade name, the trade name must also be registered. If the business is a SOLE PROPRIETORSHIP which uses a trade name, the trade name must be registered with the Business Division (701-328-4284). Yes No If yes, provide the number _____________________. 5. Does the applicant have a North Dakota Sales and Use Tax permit? For information regarding this permit, contact the North Dakota Tax Department at 701-328-3470. 6. North Dakota Century Code, Section 43-07-04 requires an applicant to submit to the Secretary of State a statement from North Dakota Workforce Safety & Insurance that the applicant has secured satisfactory WORKERS COMPENSATION coverage. If you do not have any employees, an affidavit of nonemployment is required to be filed. For details, contact the Workforce Safety & Insurance, 1600 East Century Avenue Suite 1, Bismarck, North Dakota 58506, (701-328-3800) or (800-777-5033). 7. In compliance with the Federal Privacy Act of 1974, the disclosure of the social security number or Federal ID number on this form is voluntary. They are not disclosed to the public. The numbers are used by the Secretary of State to maintain accurate contractor files. Therefore, while voluntary disclosure is requested, failure to do so will not invalidate this application. For the purpose of qualifying for a contractor's license, the applicant submits, under oath, the following information: A. Business Type Sole Proprietorship - Complete C Below General Partnership - Complete C & D Below Limited Liability Partnership - state of origin __________ Complete C & D Below C. Name of Owner (or General Partner or Managing Partner) Complete Mailing Address D. Name of General Partner (or Managing Partner) Complete Mailing Address City City Social Security/Federal ID# B. Business Federal ID # Limited Liability Company - state of origin _________ Corporation - state of origin _________

Social Security/Federal ID#

Home Telephone # State Zip Code

Home Telephone # State Zip Code

8. North Dakota Century Code, Section 43-07-04 requires an applicant to file a CERTIFICATE OF INSURANCE indicating liability coverage as proof that the applicant has secured liability insurance. Any contractor who fails to maintain liability insurance coverage shall have their license revoked. 9. In addition to a contractor's license, you may need to obtain other licenses or permits as required by law (e.g. the State Electrical Board, the State Plumbing Board, Transient Merchant License from the Attorney General or Asbestos Abatement from the Health Department). (continue on reverse side)

SFN 12012 (12-07) Page 2 10. Do you hold a contractor license in another state? Yes No If Yes, indicate the state(s) in which you are licensed, the business name under which you are licensed, licensing agency address and telephone number Telephone # City State Zip Code

Business Name Licensing Agency and Address

11. The applicant's experience and/or qualifications to act in the capacity of a contractor are as follows:

12. If your answer is "YES" to any of the following questions, give the details on a separate sheet and attach to this application. a. Has any license been denied, suspended or revoked For you? Yes No For any officer? For any partner? For any entity with which you, officers or partners have or are associated with? Yes Yes Yes No No No

b. Have there been any civil lawsuits or arbitration proceedings in which you (or a corporation, limited liability company, or partnership of which you are or were an officer or partner) were involved as a defendant in which fraud or misrepresentation was charged during the past year? Yes No As a Defendant Yes No As a Plaintiff c. Have you or a corporation, limited liability company, or partnership of which you are or were an officer or partner, been involved in bankruptcy proceedings during the past five years? Yes No d. Are there any judgments, arbitration awards, mechanics liens or federal or state tax liens against you, or a corporation, limited liability company, or partnership of which you are an officer or partner, in North Dakota or elsewhere? Yes No e. Has the applicant, or officers or partners of the applicant been charged with or convicted of a felony or misdemeanor within the last five years? Yes No If Yes, indicate the date, name of the individual charged or convicted, city, state, disposition, and whether a felony or misdemeanor. (This includes ALL crimes, including nonsufficient funds checks, no account checks, and DUIs.)

13. Once the licensing process has started and the requirements are not completed or perfected within 90 days, one half of the filing fee submitted will be retained and the other half returned to the applicant. 14. North Dakota Century Code, Section 43-07-19 states every applicant who is not a resident of the state of North Dakota, by signing and filing the application appoints the Secretary of State as the applicant's true & lawful agent upon whom may be served all lawful process in any action or proceeding against such non-resident contractor.

AFFIDAVIT
(Sign before a notary) The Applicant, who is 18 years of age or older, whose name is ________________________________________________________________, being first duly sworn on oath deposes and says he/she is the applicant above named, or the ______________________________________ of the corporation or a member of the firm, association, or co-partnership which has caused said application to be filed, and that he/she is duly authorized and empowered to make this affidavit for and on behalf of said applicant; that he/she has read the within and foregoing application and knows the contents thereof, and that the statements therein contained are true of his/her own personal knowledge, except as to such statement therein made upon information and belief, and as to such statements he/she believes the same to be true. State of ______________________ County of ____________________ The foregoing instrument was acknowledged before me this ________ day of _______________________, 20 _______. Signature of Applicant

(Notary Seal/Stamp)

Notary Public My Commission Expires______________________________