Contractor License & Insurance Verification "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.TitleCONTRACTOR INFORMATIONContractor NameName of Business*Business Address*Address 2City*State / Province*Zip/Postal Code*PhoneMobile PhoneFax*Email Business License Type Sole Proprietor Partnership Corporation Contractor Type General Contractor Sub Contractor Type of work performed by ContractorINSURANCE VERIFICATIONInsurance CompanyPolicy NumberExpiration Date * Proof of public liability and property damage insurance policy insuring the above listed contractor and naming the Town of Newburgh, Indiana as “additional insured” in an amount of not less that Five Hundred Thousand ($500,000.00) with a fifteen (15) day notification of cancellation. Upload Certificate of Liability* Drop files here or Select files Accepted file types: doc, docx, pdf, xls, xlsx, jpg, gif, png, Max. file size: 20 MB, Max. files: 10. INDIVIDUALS AUTHORIZED TO SECURE PERMITS UNDER THIS LISTINGAuthorized Personnel All individuals within the company are authorized to secure permits. The following individuals are authorized to secure permits (attach separate sheet if more lines are needed) Name 1Name 2Name 3CERTIFICATIONThe undersigned certifies to the correctness of the above information and agrees to abide by the Building and Zoning Codes of the City of Novo and all ordinances and regulations governing all work in connection with operations under said license. SignatureYour NameYour NameYour NameYour NameForm CompletionTotal Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Δ