Provided _____ _ ____ _ 1.) Qualifie r s Driver License 2.) City Occupational License/BusinessTax 3.) S tate Certification License, or Registration, Broward County Certificate Competency 4.) Workers Compensation/Exemption 5.) General Certificate of Liability Insurance* Certificate of Insurance must list the "City of Hollywood" as the certificate holder.* I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Qualifier Signature The foregoing instrument was acknowledged before me this day of 20 by who is personally known to me or has produced Notary Public Signature Rev. 9/ 24 Contractor Registration Form as identification and did (or did not) take an oath. Date NOTARY STAMP HERE Update License Type: Mobile Ph# : P lease select one: New Qualifier Name : Qualifier License# Business Name : Business Address : Business Phone #: Quali fier Email Address: Please note: Copies of the following documents must be submitted with this Contractor Registration form in pdf format.