Required fields are marked with asterisks (*)

Application For Certificate Of Registration As A Licensed Electrical Contractor

All applications, licenses and permits are subject to approval.

Application is herewith made to the City of Mt. Vernon for a certificate of registration as a Licensed Electrical Contractor within the Corporate Limit of the City of Mt. Vernon, IL.

In accordance herewith we are posting a Bond of $50.00 with the City Clerk, are paying the required fee of $40.00 which, upon approval of the Electrical Inspector and the issuance of a Certificate of Registration by the City Clerk, we will be authorized to engage in the business of Electrical Contracting in the City of Mt. Vernon for the current fiscal year ending the first day of May, while the certificate remains unsuspended or revoked.

Name (Firm or Individual)

Address

Phone Number

Email Address

Name of Individual (Supervising Electrician)

Supervising Electrician Birth Date

Experience: Places you have worked as an electrician for the past 4 years. Please list most recent first.

Name and Address

Dates Employed (From-To)

Name of Supervisor

Add Remove

Name and Address

Dates Employed (From-To)

Name of Supervisor

Name and Address

Dates Employed (From-To)

Name of Supervisor

Name and Address

Dates Employed (From-To)

Name of Supervisor

Describe any specialized training (High School, College, etc.)

Please upload proof of qualifications

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Date

I certify that the information provided is true, accurate, and complete. I understand that the completion of this application does not guarantee approval

Yes

For Office Use Only

Fee Payment Received and Bond Approved by the City Clerk

Electrical Inspector: Date:

City Clerk: Date: