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City of Oldsmar Authorization to Sign Applications

  1. _________________________________________
    Date
  2. _________________________________________
    Print Name of Qualifier
  3. _________________________________________
    Qualifier's Company Name
  4. _________________________________________
    Email
  5. _________________________________________
    Company Address
  6. _________________________________________
    Qualifier's License #
  7. SIGNATURE OF CERTIFIED CONTRACTOR MUST BE NOTARIZED. THE FOLLOWING INDIVIDUALS FROM THE ABOVE FIRM ARE AUTHORIZED TO SIGN PERMITS FOR MY COMPANY IN THE CITY OF OLDSMAR:
  8. _________________________________________
    Print Individual Name
  9. _________________________________________
    Sign Individual Name
  10. _________________________________________
    Print Individual Name
  11. _________________________________________
    Sign Individual Name
  12. _________________________________________
    Print Individual Name
  13. _________________________________________
    Sign Individual Name
  14. Authorization for the above individuals to sign for permits for my company will remain in effect until further notification from this company is provided to The City of Oldsmar. I am aware that if any changes are made by my company regarding the above information, it is my responsibility to notify The City of Oldsmar.
    Signature of Certified Contractor ____________________________________________
  15. STATE OF FLORIDA
    COUNTY OF _______________________________
  16. Sworn to and subscribed before me this ___________ day of _________________, 20______.
    By _______________________________________.
  17. Notary Public, State of Florida (Print, type or stamp name)
    ____________________________________________
  18. Seal:
  19. Identification
  20. _________________________________________
    Type of identification produced: Include ID #
  21. Leave This Blank: