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Contractor Registration Form

2. 
3. West Melbourne | Building Division
   2240 Minton Road | West Melbourne, FL 32904
   Tel: 321.837.7776 | Fax: 321.952.9542
   www.westmelbourne.org
4. Contractor Registration Form
6. Please select one:*

   1. New Registration

   1. Update Information
8. Name of Qualifier*
9. Company Name*
11. Business Address*
13. City
14. State
15. Zip
17. Phone*
18. Fax
20. Email
22. For proper registration, you shall provide all updated information that apply to your contractor's qualifications. Incomplete and missing information will delay the registration process, and as a result no applications for permit will be properly processed.
24. * Certified Contractor (State License).
25. Trade
27. * Brevard County Contractor (Certificate of Competency).
28. Trade
30. * Liability Insurance (City of West Melbourne as certificate holder).
32. * Workman's Compensation (City of West Melbourne as certificate holder) or Florida's exemption.
34. * Business Tax Receipt (Former Occupational License).
36. Name of Authorized Person to submit and pickup permit applications:
38. Phone
39. Email
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field