Application for Contractor Registration/License

The Registration Fee shall be $40.00 per year beginning on July 1st and ending June 30th of the succeeding year.

Business Location Address

Legal Business or Corporate Name:*

DBA, Division or Subsidiary:*

Owner’s Name (If sole Owner):*

Address:*

Street Address Address Line 2 City State ZIP Code

Name:*

Address (Street or PO Box ):

Street Address Address Line 2 City State ZIP Code

Name of Contact Person:*

Phone Number of Contact Person:*

Email of Contact Person:*

Corporation, Partnership, Individual or other – enter FEIN in blocks:

WV Identification Number

If you are the sole owner you must also enter your SS#:

Description of Business:

Check Appropriate Type of Business