Application for Additional Classification

Classification requesting (check):

"A" - General Engineering Contracting

"B" - General Building Contracting

"C" - Specialty Contracting. Indicate symbol(s):

If applicant is a corporation, partnership, J/V, LLC, LLP, provide:

If applicant is a Responsible Managing Employee (RME), provide:

Employer (if self-employed, so state)

Description of Work in Detail

Dates (Month/Yr) From

To

List Names of five (5) major projects you have supervised in classification being requested.

1)

2)

3)

4)

5)

Outline scope of work performed by you as a supervisor:

Add Class ....................... 120 ................. $50

Service Charge ................. BCF ................. $25

Name of Applicant

Classification requesting (check)

A - General Engineering

B - General Building

C -

C -

Indicate your BUSINESS RELATIONSHIP to the applicant:

EMPLOYER

SUPERVISOR

RME Lic. #

Classifications held:

Employment Dates (mo/yr): From

To

Indicate LEVEL applicant worked at:

JOURNEYMAN

FOREMAN

SUPERVISOR

CONTRACTOR

OTHER (Specify)

Length of service: Yrs.

mos.

Dates applicant has supervised: From

To

TOTAL TIME:

Did the applicant demonstrate a level of knowledge and skill expected of a journeyman or better in the craft(s) of trade(s) listed above?

YES NO

FULL-TIME

PART-TIME

Did the applicant demonstrate a history of honesty, truthfulness, financial integrity and fair dealing?

YES NO

DESCRIBE IN DETAIL THE TYPE OF SUPERVISORY WORK PERFORMED BY THE APPLICANT:

Certification of Person Completing this Form:

I, hereby certify that I have personally known the person named as applicant above; that I have direct knowledge of the applicant's supervisory experience which I have listed above; and, all other statements and answers given here are true and correct.

Financial Statement as of , 20 (not more than one year old) is for:

Name of Applicant:

(Sole Proprietor, Corporation, Partnership, Joint Venture, LLC, LLP)

Note: The name listed on this financial statement must be exactly the same name listed on your application under "Name of Applicant".

This statement must be signed, whether accountant uses this form or his own.

I hereby certify as owner, officer, partner, manager, member or R.M.E. that the statements contained on this statement are true and correct. I certify that any misrepresentation is grounds for refusal or subsequent revocation of license and is a misdemeanor (Sec. 710-1017, Sections 436B-19, and 444-17, Hawaii Revised Statutes).

In the opinion of the undersigned, the above statement fairly presents, on the date indicated, the financial condition of the applicant. The undersigned has no interest in the above enterprise.

SHALL BE PREPARED AND SIGNED BY A LICENSED PUBLIC ACCOUNTANT OR CERTIFIED PUBLIC ACCOUNTANT HOLDING A CURRENT PERMIT TO PRACTICE. IF LICENSED IN ANOTHER STATE, PROVIDE COPY OF A CURRENT LICENSE. Note: Financial Statements prepared by bookkeepers and tax preparers are not acceptable.