Roofing Invoice

New/Renewal Application for Roofing Contractor Registration

Construction Industries Board

2401 NW 23rd, Suite 2F

Oklahoma City, OK 73107

Telephone: (405) 521-6550 Toll Free: 1-877-484-4424

Web site: http://ok.gov/cib/

Information Required for New/Renewal Application for Roofing Contractor Registration

Roofing Registration (New/Renewal) Fees: $75.00

Renewals Received after August 1st: $150.00 (Includes Renewal Fee and Late Fee)

After January 1st your registration will be revoked

Reinstatement Fee: $300.00

Instructions:

1. Return completed application with new or renewal registration fee to address listed above.

NOTE: Please make remittance payable to the CONSTRUCTION INDUSTRIES BOARD or CIB. (CREDIT CARDS NOT ACCEPTED)

2. Provide the following information with the application:

a. Certificate of General Liability Insurance, minimum $500,000.00 (Construction Industries Board w/ name and address, must be listed as a certificate holder.) Note* Roofer’s name must be listed as insured along with company name.

b. Certificate of Workers’ Compensation or Affidavit of Exemption or Self-Insurance CompSource (405) 232-7663 (Construction Industries Board must be listed as a certificate holder).

c. Certificate of Good Standing from Oklahoma Secretary of State (for Oklahoma domestic and registered foreign corporations, LLC’s, limited partnerships *must be updated annually*) (405) 521-3911. This is not required for Sole Proprietors or Partnerships.

d. Trade Name Report from Oklahoma Secretary of State (for Oklahoma domestic and registered foreign corporations, LLC’s, limited partnerships, sole proprietors, and partnerships if Doing Business As, *must be updated annually*) (405) 521-3911.

e. Affidavit verifying lawful presence in the United States.

**Certificate Holder must be shown as:

Construction Industries Board

2401 NW 23rd Street, Suite 2F

Oklahoma City, OK 73107

New/Renewal Application for Roofing Contractor Registration

(Important: Registration fee must accompany application.)

Date of application:

Applicant Must Check One:

Resident Contractor:    Non-Resident Contractor:

New    Renewal of Registration

Type or print in ink all information.

Individual contractor information:

Registration Number (Renewals):

1. Name

2. Physical Address

3. Telephone:

4. Birthdate: Age: SSN:

5. Brief description of experience and qualifications:

Business information:

6. Type of Business Entity: Corporation   LLC   LLP   Sole Proprietorship   Partnership

7. State of Formation:

8.

9.

10. Business Phone: Business Fax:

11. Trade (DBA) Name:

12. Authorized Persons to Act on Behalf of Business: (attach additional sheets if necessary.)

Name:

Address:

Telephone: Cell Phone:

Email address:

13. Has the applicant or entity seeking registration herein ever been licensed or registered as a roofing contractor in a state other than Oklahoma? If yes, please list all states where such license or registration is/was held and whether each license or registration is currently in good standing.

Yes No

14. Has the applicant or entity seeking registration herein ever been disciplined, fined, sanctioned, cited or had its license or registration to perform work as a roofing contractor suspended or revoked in any state other than Oklahoma? If yes, please specify the State of such event and nature of occurrence and date of action taken.

Yes No

15. Have you ever been convicted of a felony offense in this State, another State, or any other place?

Yes No

If yes, list the date, court of conviction, offense by each count(s), sentence for each such conviction and date of sentence completion, including any probation, parole or supervision period.

59 O.S. § 1151.6(B) Conviction of an offense shall not disqualify a person from registration as a roofing contractor under this act; provided, the applicant has truthfully disclosed the conviction and nature of the offense.

16. Are you required by the laws of the State of Oklahoma, any other State, or the United States to register as a sex offender?

Yes No

17. If you answered yes to question 16, have you registered with the State Of Oklahoma?

Yes No

Instructions for Required Affidavit:

All natural persons fourteen (14) years of age or older and present in the United States, applying for a license with the Oklahoma Construction Industries Board are required, by the provisions of 56 O.S. § 71, to provide the Board with verification of lawful presence in the United States by executing the Affidavit shown below before a notary public or other officer authorized to notarize affidavits under State law. The Board’s licensing offices are staffed with notaries who are available to provide notary service at no cost to Applicants.

AFFIDAVIT VERIFYING LAWFUL PRESENCE IN THE UNITED STATES

Affidavit of

I , of lawful age, being first duly sworn, upon oath state, under penalty of perjury, as follows:

Please check the appropriate box:

Option 1: I am a United States Citizen.

Option 2: I am a qualified alien under the federal Immigration and Naturalization Act, and I am lawfully present in the United States. For this Option, a copy of a valid immigration document which reflects the applicant's "A" number or "I-94" number must accompany this Affidavit.

______________________________

[Signature of Applicant]

Subscribed and sworn to or affirmed before me this day of , 20, by .

______________________________

[Signature of Notary]

My Commission Expires:

My Commission Number: (Notary Seal)