APPLICATION TO CHANGE OR ADD A QUALIFIED EMPLOYEE. General Instructions

Transcription

1 NEVADA STATE CONTRACTORS BOARD 2310 Crprate Circle, Suite 200, Hendersn, Nevada, (702) Fax (702) Investigatins (702) Kietzke Lane, Suite 102, Ren, Nevada, (775) Fax (775) Investigatins (775) Website: APPLICATION TO CHANGE OR ADD A QUALIFIED EMPLOYEE 1. Please type r print in ink when cmpleting this frm. 2. Make sure this applicatin is prperly signed by a principal. 3. Include the required applicatin fee f $ General Instructins 4. Read all instructins carefully. The Bard desires t prvide curteus and timely service t all applicants. T maximize its efficiency and the level f service, the Bard will prcess cmplete applicatins nly. A cmplete applicatin includes all applicable supprting dcuments and fees. The Bard will nt act as yur agent in gathering infrmatin r supprting dcuments necessary fr the cnsideratin f yur license applicatin. Incmplete applicatins will be returned t yu. 5. Leave n space blank. If a particular questin r request fr infrmatin des nt apply t yu, put NA in the blank space t indicate the questin has received yur attentin. 6. NOTE: This applicatin cannt be used t change crprate fficers, if a crpratin, r managing members, if a limited liability cmpany. If the lss r additin f a qualified emplyee has resulted in a change t yur crprate fficers r managing members, a separate change applicatin will be required. SECTION 1 BUSINESS NAME & LICENSE NUMBER Business Name: Use the legal business name as it appears n yur license. If there has been a change in yur legal business name, a separate change f name applicatin is required. Legal Business Name: (Use Name as Set Frth n the License) License Number: Phne N.: ( ) Address: Facsimile N.: ( ) SECTION 2 QUALIFIED PERSONNEL Persnnel: Supply the identifying infrmatin belw nly fr each individual that will be added as a qualified emplyee t this license. *If there are multiple sub-classificatins within the classificatin fr which yu are licensed, the trade qualifier must substantiate experience fr the full scpe f yur license. Separate qualifiers fr individual sub-classificatins are nt allwed. Backgrund Disclsure Statement: A separate backgrund disclsure statement must be cmpleted fr each individual listed belw. The required frm is n page 6 f this applicatin. FIRST NAME MIDDLE NAME LAST NAME TITLE FIRST NAME MIDDLE NAME LAST NAME TITLE FOR OFFICE USE ONLY DO NOT WRITE IN THIS SPACE Date Received: Amunt: Receipt #: File N.: Withdrawn Date: Reasn: Applicatin N: Apprved: Denied: Transactin Clsed: Date: Entered by: QI: CMS TRD; File#: Type: PQ App #: Status: A D W QI: CMS TRD; File#: Type: PQ App #: Status: A D W Nevada State Cntractrs Bard Rev 12/16 Page 1 f 14

2 SECTION 3 DISASSOCIATION OF QUALIFIED EMPLOYEE The purpse f this applicatin is: Add a qualified emplyee Replace the existing qualified emplyee Disassciatin f Qualified Emplyee: Check the apprpriate bx t indicate whether r nt the current qualified emplyee is still assciated with this licensee, r if they have terminated their emplyment r assciatin. The qualified emplyee currently listed n this license is still an emplyee, fficer, directr, manager, r assciate f this licensee. The qualified emplyee currently listed n this license terminated their emplyee r assciatin with this licensee effective n the fllwing date:. SECTION 4 CONTRACTORS LICENSES If yu r anyne appearing n this applicatin have EVER been listed n a cntractr s license in Nevada r ANY ther state at any time past r current please fill in the infrmatin belw fr all licenses btained. Past licenses include ANY licenses that are revked, suspended, withdrawn, inactive, cancelled, etc. Indicate N/A in the field belw if yu have nt. Cmpany Name State License # Issue Date License Status SECTION 5 EXPERIENCE QUALIFICATIONS (ATTACH A SEPARATE SHEET IF NECESSARY) Qualified Emplyee (Qualifier): The qualifier can be an wner, fficer, member, manager r emplyee f the cmpany. Yu may have mre than ne qualified emplyee. Each qualifier must be a bna fide member r emplyee f this cmpany, and when yu are actively engaged in the cntracting business, the qualified emplyee shall exercise authrity in the fllwing manner: T make technical and administrative decisins; Hire, superintend, prmte, transfer, lay ff, discipline r discharge ther emplyees and direct them, either by himself r thrugh thers, r effectively t recmmend such actin n behalf this cmpany; and T devte himself r herself slely t this business, nt taking any ther emplyment that wuld cnflict with his r her duties. Management Qualifier: This individual must take and pass the cnstructin management survey examinatin. This exam includes tpics such as general knwledge f the Nevada cntractrs law, mechanics lien law, laws regarding industrial insurance, and cmmn knwledge f business administratin. Trade Qualifier: This individual must have, within the 10 years immediately preceding the filing f this applicatin, at least 4 years f experience as a jurneyman, freman, supervising emplyee r cntractr in the specific classificatin requested. Training received in a prgram ffered at an accredited cllege r university r an equivalent prgram accepted by the Bard may be used t satisfy nt mre than 3 years f experience. A jurneyman is defined as a persn wh is fully qualified t perfrm, withut supervisin, wrk in the classificatin applied fr; r has successfully cmpleted a prgram f apprenticeship that has been apprved by the state apprenticeship cuncil, r equivalent prgram accepted by the Bard. Nevada State Cntractrs Bard (Revised 12/16) Page 2 f 14

3 * If there are multiple sub-classificatins within the classificatin fr which yu are requesting t braden, the trade qualifier must substantiate experience fr the full scpe f wrk fr which yu are applying. Separate qualifiers fr individual subclassificatins are nt allwed. Reference Certificates: Yu are required t submit with this applicatin, fur (4) Reference Certificates (certificates) fr each trade qualifier. The certificates shuld be cmpleted by emplyers, ther than the applying cmpany, r if a self-emplyed cntractr, by custmers fr whm the wrk was perfrmed. The certificates must verify the experience requirements as stated abve. Relatives cannt cmplete the certificates, unless that relative was yur emplyer. References that are nt cmplete r nt specific regarding the actual wrk perfrmed will nt be accepted. Any reference determined t be false r misleading may be cnsidered misrepresentatin r missin f a material fact, in vilatin f NRS (2). The required certificatin frms are n pages Resume f Experience: Cmplete the Resume f Experience frm fund n page 17 fr each trade qualifier. Include name, current address, phne number and dates f emplyment fr each emplyer. Describe in detail the wrk perfrmed. Specify type(s) f cnstructin prjects, trades(s), craft(s), tasks and duties perfrmed. If self-emplyment is being relied upn t establish any prtin f the experience requirement, include n the Resume f Experience frm custmers fr whm yu wrked, including their cmplete mailing address and phne number. Previusly Qualified and Reciprcal Applicants: The Reference Certificates and Resume f Experience may nt be required if yu: 1. Have served as a qualified emplyee in the same classificatin n anther Nevada state cntractr s license within the last five (5) years; r, 2. If yu meet the terms f reciprcity described in sectin 6. Imprtant Ntice: If fr any reasn yur qualified emplyee(s) terminates his r her emplyment r assciatin with this license yu are required t ntify the Nevada State Cntractrs Bard, in writing, within ten (10) days, and replace that individual(s) within 30 days. Failure t d s will result in autmatic suspensin f the license. Ownership Requirement: A qualified individual may nt qualify n behalf f anther fr mre than ne active license unless that individual wns at least 25% f each licensee fr which he r she qualifies; r ne licensee wns at least 25% f the ther licensee. If yu will be qualifying mre than ne active license, ther than a sle prprietrship wned by yu, attach prf f wnership fr each license. SECTION 6 EXAMINATION REQUIREMENTS Examinatin Requirements: A management (CMS) and trade examinatin will be required. The trade exam will be specific t the classificatin requested. Yu will receive an Examinatin Eligibility frm after the applicatin is submitted and experience is verified. Candidate infrmatin bulletin, exam cntent utlines, and rder frms fr the CMS exam and trade exam(s) reference manuals are available n the Bard s website. Examinatin Fees: $140 when the CMS and ne Trade Exam are scheduled at the same time OR $95 per each exam. Cntact PSI Exams at (800) fr additinal examinatin details and infrmatin. Yu May Be Eligible fr Waiver f An Exam If: 1. Current/Recent Nevada Qualified Emplyee: If yu have served as a qualified emplyee n a license in the State f Nevada in the same classificatin requested in gd standing within the last 5 years. 2. B r B-2 Exam Waiver: Applicants fr a full B General Building r B-2 Residential and Small Cmmercial license may be cnsidered fr waiver f the trade exam if they have passed the Natinal Assciatin f State Cntractr Licensing Agencies (NASCLA) Accredited Exam administered by PSI. Trade Qualifiers must submit a cpy f their transcript frm NASCLA alng with 4 Reference Certificates and a cmpleted Resume f Experience. If yu are applying fr the B General Building license, yu will be required t submit 4 Reference Certificates and a cmpleted Resume f Experience that demnstrate experience in cmplete cnstructin f high rise structures. 3. Reciprcity Exam Waiver Please fill ut the frm lcated n page 10. The Bard reserves the right t require an examinatin f any applicant regardless f current r previus licensure. Nevada State Cntractrs Bard (Revised 12/16) Page 3 f 14

4 I am requesting NSCB waive the exam requirements based n my prir licensure in the States f Arizna, Califrnia, Nevada, and/r Utah: COMPANY NAME LICENSE # STATE SECTION 7 - SIGNATURE OF QUALIFIED EMPLOYEE AND CERTIFICATION OF DUTY I certify under penalty f perjury that I will act in the capacity f the qualified emplyee fr this licensee and perfrm the duties required f me pursuant t Chapter 624 f the Nevada Revised Statues and Nevada Administrative Cde, Chapter 624. If at any time I cease t be emplyed by, r assciated with this cmpany, I will immediately prvide written ntificatin t the State Cntractrs Bard. (TWO SPACES ARE PROVIDED IN THE EVENT YOU HAVE MORE THAN ONE QUALIFIER) I will be acting in the fllwing capacity: Management Qualifier (This is the individual that will take r has already taken the cnstructin management examinatin) Trade Qualifier (This is the individual that has demnstrated the necessary technical experience, and will take r has already taken the trade examinatin.) Bth Management and Trade Qualifier (Signature) (Date) (Print Name) I will be acting in the fllwing capacity: Management Qualifier (This is the individual that will take r has already taken the cnstructin management examinatin) Trade Qualifier (This is the individual that has demnstrated the necessary technical experience, and will take r has already taken the trade examinatin.) Bth Management and Trade Qualifier (Signature) (Date) (Print Name) Nevada State Cntractrs Bard (Revised 12/16) Page 4 f 14

5 SECTION 8 AFFIDAVIT AND AUTHORIZED SIGNATURE I am authrized t sign this Affidavit and Release Authrizatin n behalf f the applicant described and identified in this applicatin. The applicant is qualified in all respects fr the license fr which it is applying in this applicatin. T the best f applicant s knwledge, the infrmatin cntained in the applicatin and its supprting dcuments are free f fraud, misrepresentatin, r missin f material fact. T the best f applicant s knwledge, the infrmatin cntained in the applicatin and its supprting dcuments are truthful, crrect, and cmplete; and, disclses all material facts regarding the applicant and assciated individuals necessary t prperly evaluate the applicant s qualificatin fr licensure. Applicant will ensure that any infrmatin subsequently submitted t the Bard in cnjunctin with this applicatin r its supprting dcuments meet the same standard as set frth abve. Applicant understands t apply fr r btain a license r t therwise deal with the Nevada State Cntractrs Bard thrugh the use f fraud, frgery, intentinal deceptin, misrepresentatin, misstatement, r missin is cause fr denial f this applicatin. Applicant understands that this applicatin will be classified as a public recrd and will be available fr inspectin by the public, except with regard t the release f infrmatin classified as cnfidential pursuant t NRS Cnfidential infrmatin includes; credit reprts, references, financial infrmatin, and investigative memranda. Applicant understands that the Nevada State Cntractrs Bard has the authrity t cnduct apprpriate backgrund investigatins fr the purpse f verifying all statements and facts represented in this applicatin and supprting dcumentatin. Signature Requirements: A principal f the applying cmpany must sign this applicatin. By: (Signature) Title: (Print Name) Date: Nevada State Cntractrs Bard (Revised 3/27/17) Page 5 f 14

6 SECTION 9 BACKGROUND DISCLOSURE (Pages 6-8) Yu MUST include ANY and ALL criminal cnvictins incurred as an individual r as the principal f a crpratin r ther business entity. Failure t disclse a cnvictin is misrepresentatin r missin which vilates NRS (7) and NRS (2). Reprtable ffenses include any f the fllwing, whether yu pled guilty r n cntest, AND regardless f the utcme f the case: Nn-vilent misdemeanr, including DUI, within the past (15) years Misdemeanr crimes invlving vilence against anther persn, fraud r theft Felny cnvictins r felny arrests (even if charges were reduced/dismissed). I understand the Bard utilizes infrmatin frm the Federal Bureau f Investigatins (FBI) and the Nevada Criminal Histry Repsitry t cmpare with the infrmatin I disclse n this applicatin. I am aware that these recrds are likely t include all instances f criminal activity, including thse matters that may have been sealed, expunged, had the charges reduced r dismissed. I understand it is my respnsibility t be hnest abut any such activities that have ccurred in my life and I will err n the side f cautin by including any and all such instances. My applicatin will nt be autmatically denied because f infrmatin btained thrugh the backgrund disclsure and criminal histry verificatin. When reviewing prir criminal cnvictins, the NSCB cnsiders such additinal factrs as the seriusness f the crime, the time that has passed since the cnvictin and any evidence f rehabilitatin the applicant submits. If yu misrepresent, mit r lie n yur applicatin, yur applicatin MAY be denied. If yu have any questins cncerning the disclsure f arrests r cnvictins, please call the Investigatins Department f the NSCB, at in Hendersn r in Ren. FINANCIAL DISCLOSURES Yu MUST disclse any unpaid r unreslved liens, lawsuits, judgments and claims, including tax claims. Yu are advised t btain a cpy f yur credit reprt, Experian recmmended, which will prvide yu with any unpaid, unreslved liens r claims, all lawsuits, and all judgments. Pay particular attentin t any tax claims r liens that have been made r filed against yu. If yu have entered int any repayment r credit cnslidatin agreements, attach cpies f thse agreements t yur applicatin. I HEREBY CERTIFY I HAVE READ THIS NOTICE. NAME: SIGNATURE: Nevada State Cntractrs Bard (Revised 3/27/17) Page 6 f 14

7 NEVADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION BUSINESS NAME: NRS and NRS authrizes the Nevada State Cntractrs Bard (NSCB) t cnduct backgrund investigatins, btain credit reprts, and t request fingerprints fr submissin t the Nevada Highway Patrl (NHP) and the FBI fr a determinatin f identity, fugitive status r prir criminal histry. A separate frm MUST be cmpleted by EACH Principal and Qualified Emplyee Fr Bard Staff Only Live Scan Prints Hard Cpy Prints ***A COPY OF A VALID DRIVER S LICENSE OR GOVERNMENT ISSUED PHOTO I.D. MUST ACCOMPANY THIS FORM. *** FIRST NAME MIDDLE NAME LAST NAME TITLE DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER OTHER NAME USED, (IF APPLICABLE) SEX RACE HEIGHT WEIGHT HAIR COLOR EYE COLOR RESIDENCE ADDRESS (AND MAILING ADDRESS IF DIFFERENT) CITY STATE ZIP ADDRESS MARRIED (Fr Sle Prprietrs Only) YES / NO 1. Have yu ever, as an individual r principal f a crpratin r ther business entity, been cnvicted f, r pled guilty r n cntest t a felny crime? N Yes Yu must cmplete a criminal disclsure statement fr EACH incident. 2. Have yu ever, as an individual r principal f a crpratin r ther business entity, been cnvicted f, pled guilty, r n cntest t any misdemeanr crime? (Limit t misdemeanr cnvictins within the last 15 years, UNLESS the crime invlved vilence against anther persn, fraud r theft). N Yes Yu must cmplete a criminal disclsure statement fr EACH incident. 3. Are there currently criminal charges pending against yu? N Yes Attach a detailed explanatin, including a cpy f the cmplaint, and/r charging dcument. 4. Within the last 7 years, have yu filed r been adjudicated Bankrupt under yur individual name, a crprate name r any ther business entity name? N Yes Attach a cpy f the discharge dcument. If discharged less than 3 years, attach a cmplete cpy f the prceedings, including a schedule f creditrs listed in the bankruptcy petitin. If the bankruptcy has nt been discharged, include yur plan f rerganizatin and prf f cmpliance. 5. D yu anticipate filing bankruptcy within the next 6 mnths? N Yes 6. Have yu, r any business entities f which yu were a member, partner, fficer, directr, r assciate received any ntice f liens, suits, judgments, r claims (including tax claims) which remain unreslved r unsatisfied OR have yu entered int payment agreements regarding past due taxes r ther debts? N Yes Attach a detailed explanatin. 7. Are there nw any unpaid past due bills fr materials, services rendered, r labr? N Yes Attach a detailed explanatin. 8. Have yu, r any business entities f which yu were a member, partner, fficer, directr, assciate, r qualified emplyee had a cntractr s license denied, suspended, revked, r therwise disciplined BY NEVADA OR ANY OTHER STATE? Are there any disciplinary prceedings currently pending against yu, r any license n which yu have appeared IN NEVADA OR ANY OTHER STATE? N Yes Attach a detailed explanatin including the name f the state in which the license was held, license number, and business name. 9. D yu have a prprietary interest (i.e., wnership, stck, shares) in this applicant? (This questin des nt pertain t sle prprietrs) N Yes Percentage Owned: % 10. Are yu a citizen f the United States f America? N Attach a cpy f INS card and Scial Security Card. Yes Nevada State Cntractrs Bard (Revised 3/27/17) Page 7 f 14

8 Applicant Backgrund Disclsure Statement Authrizatin fr Release f Infrmatin In rder t cmply with the requirements f Nevada s Department f Public Safety, fingerprint cards and LiveScan fingerprints cannt be accepted until after yu submit yur applicatin and cmpleted Fingerprint Backgrund Waiver frm(s) t the Bard. Once these frms has been submitted t the Nevada State Cntractrs Bard yu may prceed with btaining the required fingerprints. In Cnsideratin fr prcessing my applicatin fr a Nevada State Cntractr s License, I, the undersigned whse name and persnal infrmatin vluntarily appear abve, d hereby and irrevcably agree t the fllwing: 1. I hereby authrize the NEVADA STATE CONTRACTORS BOARD (hereinafter BOARD ) t submit a set f my fingerprints t the Nevada Department f Public Safety, Recrds Bureau fr the purpse f accessing and reviewing Nevada and Natinal criminal histry recrds that may pertain t me. In giving this authrizatin, I expressly understand that the infrmatin may include infrmatin pertaining t ntatins f arrest, detainments, indictments, infrmatin r ther charges fr which the final curt dispsitin is pending r is unknwn t the abve referenced agencies. Fr recrds cntaining final curt dispsitin infrmatin, I understand that the release may include infrmatin pertaining t dismissals, acquittals, cnvictins, sentences, crrectinal supervisin infrmatin and infrmatin cncerning the status f my parle r prbatin when applicable. Further, I understand that the infrmatin may include similar infrmatin btained frm ther lcal, state and federal criminal justice agencies and may include infrmatin pertaining t cnvicted persn data, utstanding arrest warrants, missing persns and current and/r prir gaming and nn-gaming sheriff s wrk cards that were issued t me. 2. I understand that I may review and challenge the accuracy f any and all criminal histry recrds which are returned t the BOARD. 3. I hereby release frm liability and prmise t hld harmless under any and all causes f legal actin, the State f Nevada, the Nevada State Cntractrs Bard, its fficer(s), agent(s) and/r emplyee(s) wh cnducted my criminal histry recrds search and prvided infrmatin t the BOARD fr any statement(s), missin(s), r infringement(s) upn my current legal rights. I further release and prmise t hld harmless and cvenant nt t sue any persns, firms, institutins r agencies prviding such infrmatin t the State f Nevada and the BOARD n the basis f their disclsures. I have signed this release vluntarily and f my wn free will. 4. In giving the abve authrizatin, I understand that all infrmatin prvided t the BOARD may be reviewed by the BOARD r any ther emplyee within the BOARD S rganizatin deemed necessary t make an infrmed decisin. This infrmatin is cnfidential, as relating t a third party beynd that f the BOARD and f the criminal justice agencies in the perfrmance f their fficial duties, and may nt be further disseminated. (Please initial) A reprductin f this authrizatin fr release f infrmatin by phtcpy, facsimile r similar prcess, shall fr all purpses be as valid as the riginal. PURSUANT TO NRS , I CERTIFY THAT I HAVE CAREFULLY REVIEWED THE INFORMATION CONTAINED IN THIS DOCUMENT AND I ATTEST TO THE TRUTH AND ACCURACY OF THE INFORMATION CONTAINED IN THIS BACKGROUND DISCLOSURE STATEMENT UNDER PENALTY OF PERJURY. Applicant s Name: (LAST, FIRST MIDDLE) (SIGNATURE) Address: Date: T Be Cmpleted by Bard Staff Only: Submitted by: NEVADA STATE CONTRACTORS BOARD Date Submitted: 2310 CORPORATE DRIVE, SUITE 200 HENDERSON, NEVADA Agency s Representative: (PRINT) (SIGNATURE) Nevada State Cntractrs Bard (Revised 3/27/17) Page 8 f 14

9 FINGERPRINT BACKGROUND WAIVER As an applicant wh is the subject f a Federal Bureau f Investigatin (FBI) fingerprint-based criminal histry recrd check fr a nncriminal justice purpse yu have certain rights which are discussed belw. 1. Yu must be ntified by (enter name f requesting agency) _that yur fingerprints will be used t check the criminal histry recrds f the FBI and the State f Nevada. 2. If yu have a criminal histry recrd, the fficials making a determinatin f yur suitability fr the jb, license r ther benefit fr which yu are applying must prvide yu the pprtunity t cmplete r challenge the accuracy f the infrmatin in the recrd. Yu may review and challenge the accuracy f any and all criminal histry recrds which are returned t the submitting agency. The prper frms and prcedures will be furnished t yu by the Nevada Department f Public Safety, Recrds Bureau upn request. If yu decide t challenge the accuracy r cmpleteness f yu FBI criminal histry recrd, Title 28 f the Cde f Federal Regulatins Sectin prvides fr the prper prcedure t d s: Prcedure t btain change, crrectin r updating f identificatin recrds. If, after reviewing his/her identificatin recrd, the subject theref believes that it is incrrect r incmplete in any respect and wishes changes, crrectins r updating f the alleged deficiency, he/she shuld make applicatin directly t the agency which cntributed the questined infrmatin. The subject f a recrd may als direct his/her challenge as t the accuracy r cmpleteness f any entry n his/her recrd t the FBI, Criminal Justice Infrmatin Services (CJIS) Divisin ATTN: SCU, Md. D-2, 1000 Custer Hllw Rad, Clarksburg, WV The FBI will then frward the challenge t the agency which submitted the data requesting that agency t verify r crrect the challenged entry. Upn the receipt f an fficial cmmunicatin directly frm the agency which cntributed the riginal infrmatin, the FBI CJIS Divisin will make any changes necessary in accrdance with the infrmatin supplied by that agency. 3. Based n 28 CFR (b), fficials making such determinatins shuld nt deny the license r emplyment based n infrmatin in the recrd until the applicant has been affrded a reasnable time t crrect r cmplete the recrd r has declined t d s. 4. Yu have the right t expect that fficials receiving the results f the fingerprint-based criminal histry recrd check will use it nly fr authrized purpses and will nt retain r disseminate it in vilatin f federal r state statute, regulatin r executive rder, r rule, prcedure r standard established by the Natinal Crime Preventin and Privacy Cmpact Cuncil. 5. I hereby authrize (enter name f requesting agency), t submit a set f my fingerprints t the Nevada Department Public Safety, Recrds Bureau fr the purpse f accessing and reviewing State f Nevada and FBI criminal histry recrds that may pertain t me. In giving this authrizatin, I expressly understand that the recrds may include infrmatin pertaining t ntatins f arrest, detainments, indictments, infrmatin r ther charges fr which the final curt dispsitin is pending r is unknwn t the abve referenced agency. Fr recrds cntaining final curt dispsitin infrmatin, I understand that the release may include infrmatin pertaining t dismissals, acquittals, cnvictins, sentences, crrectinal supervisin infrmatin and infrmatin cncerning the status f my parle r prbatin when applicable. Revised: 10/28/13 1 Fingerprint Backgrund Waiver

10 6. I hereby release frm liability and prmise t hld harmless under any and all causes f legal actin, the State f Nevada, its fficer(s), agent(s) and/r emplyee(s) wh cnducted my criminal histry recrds search and prvided infrmatin t the submitting agency fr any statement(s), missin(s), r infringement(s) upn my current legal rights. I further release and prmise t hld harmless and cvenant nt t sue any persns, firms, institutins r agencies prviding such infrmatin t the State f Nevada n the basis f their disclsures. I have signed this release vluntarily and f my wn free will. A reprductin f this authrizatin fr release f infrmatin by phtcpy, facsimile r similar prcess, shall fr all purpses be as valid as the riginal. In cnsideratin fr prcessing my applicatin I, the undersigned, whse name and signature vluntarily appears belw; d hereby and irrevcably agree t the abve. Applicant s Name: Address: Applicant s Signature: Date: (PLEASE PRINT LAST, FIRST, MIDDLE) Submitting Agency: Address: Agency representative: (PLEASE PRINT Agency representative s Signature: LAST, FIRST, MIDDLE Date: Revised: 10/28/13 2 Fingerprint Backgrund Waiver

11 NEVADA STATE CONTRACTORS BOARD 5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, (775) FAX (775) , INVESTIGATIONS (775) CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, (702) FAX (702) , INVESTIGATIONS (702) RECIPROCITY EXAM WAIVER This frm may be cmpleted if licensure currently exists with Arizna, Califrnia, r Utah. Applicant Name Cmpany Name Street Address City State Zip INSTRUCTION TO APPLICANT Insert yur name and address and cmplete the tp prtin f this request. Give the frm t the apprpriate agency. The verifying agency will mail the cmpleted verificatin t yu at the address yu have listed. Include the cmpleted frm with yur applicatin. I am requesting licensure in the State f Nevada as a. I am/have been licensed in the State f issued under the cmpany name f. My Scial Security # is. I authrize yu t release, t the State f Nevada, all infrmatin pertaining t license number:. Print Name f Applicant Signature f Applicant NOTE TO APPLICANT: COMPLETE A SEPARATE FORM FOR EACH LICENSE NUMBER TO VERIFYING STATE: Please furnish the infrmatin requested. Sign and verify the dcument. Place the cmpleted frm in an envelpe, seal the envelpe, and prvide it t the applicant either in persn r by mail. Cmpany Name Type f License (Classificatin) Original Date f Issue Amunt f Limit (If any) License Number Amunt f Bnd (If any) Any recrd f suspensins, revcatins, ther disciplinary actins, r current Cmplaints?, If yes, please prvide a cpy f the actin. Current Status f License: If nt Active, Reasn: Name f Qualifying Individual & Title Licensed by: Waiver f Exam (Basis f Waiver): Successful Cmpletin f Exam - Specify Type: Endrsement frm the State f: Other Persnnel Listed & Titles AGENCY SEAL SIGNATURE TITLE Nevada State Cntractrs Bard (Revised 3/27/17) Page 9 f 14

12 NEVADA STATE CONTRACTORS BOARD 5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, (775) FAX (775) , INVESTIGATIONS (775) CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, (702) FAX (702) , INVESTIGATIONS (702) REFERENCE CERTIFICATE Name f Qualifying Individual: TO THE CERTIFIER: Yu must have direct knwledge f this individual s experience, and be able t certify that he r she has demnstrated a level f knwledge and skill expected f a jurneyman r better. Jurneyman is defined as a persn wh is fully qualified t perfrm, withut supervisin, wrk in the classificatin in which he r she is applying, r has successfully cmpleted a prgram f apprenticeship apprved by the state apprenticeship cuncil, r an equivalent prgram accepted by the Bard. All prtins f this frm must be cmpleted. DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED BY THIS INDIVIDUAL AT THE LEVEL OF JOURNEYMAN OR BETTER. ** LIST SPECIFIC TRADES AND DUTIES ** PLEASE TYPE OR PRINT IN INK The abve-stated wrk was perfrmed frm / / t / / Full-time Part-time (If part-time specify ttal # f years and/r mnths ) Check the bx that identifies the level that this individual wrked at while perfrming the trade(s) r craft(s) listed abve. Jurneyman Freman Supervisr Cntractr Check the bx that identifies yur business relatinship t this individual, at the time the experience was gained by them. Emplyer Unin Representative Building Inspectr Engineer Architect Cntractr Supervisr Other, specify relatinship IMPORTANT: Yu may be requested t prvide dcumentatin t verify all experience t which yu are attesting. Fr yur recrds, it is suggested that yu keep a cpy f the certificate(s) yu have cmpleted. I certify that I have direct knwledge f the wrk cvering the perid utlined abve. I certify under penalty f perjury t the truth and accuracy f the statements and infrmatin cntained herein. Number: State: (Signature f the Certifier) (Cntractr s license number and state, if applicable) (Print name) (Cmpany r business yu are affiliated with) (Address ) (City) (State) ( Zip) ( ) ( ) (Daytime Telephne Number) (Fax Number) ( Address) This Certificate Must Be Ntarized Subscribed and swrn t befre me this day f,, Ntary Public in and fr Cunty f State f. My Cmmissin Expires: Nevada State Cntractrs Bard (Revised 3/27/17) Page 10 f 14

13 NEVADA STATE CONTRACTORS BOARD 5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, (775) FAX (775) , INVESTIGATIONS (775) CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, (702) FAX (702) , INVESTIGATIONS (702) REFERENCE CERTIFICATE Name f Qualifying Individual: TO THE CERTIFIER: Yu must have direct knwledge f this individual s experience, and be able t certify that he r she has demnstrated a level f knwledge and skill expected f a jurneyman r better. Jurneyman is defined as a persn wh is fully qualified t perfrm, withut supervisin, wrk in the classificatin in which he r she is applying, r has successfully cmpleted a prgram f apprenticeship apprved by the state apprenticeship cuncil, r an equivalent prgram accepted by the Bard. All prtins f this frm must be cmpleted. DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED BY THIS INDIVIDUAL AT THE LEVEL OF JOURNEYMAN OR BETTER. ** LIST SPECIFIC TRADES AND DUTIES ** PLEASE TYPE OR PRINT IN INK The abve-stated wrk was perfrmed frm / / t / / Full-time Part-time (If part-time specify ttal # f years and/r mnths ) Check the bx that identifies the level that this individual wrked at while perfrming the trade(s) r craft(s) listed abve. Jurneyman Freman Supervisr Cntractr Check the bx that identifies yur business relatinship t this individual, at the time the experience was gained by them. Emplyer Unin Representative Building Inspectr Engineer Architect Cntractr Supervisr Other, specify relatinship IMPORTANT: Yu may be requested t prvide dcumentatin t verify all experience t which yu are attesting. Fr yur recrds, it is suggested that yu keep a cpy f the certificate(s) yu have cmpleted. I certify that I have direct knwledge f the wrk cvering the perid utlined abve. I certify under penalty f perjury t the truth and accuracy f the statements and infrmatin cntained herein. Number: State: (Signature f the Certifier) (Cntractr s license number and state, if applicable) (Print name) (Cmpany r business yu are affiliated with) (Address ) (City) (State) ( Zip) ( ) ( ) (Daytime Telephne Number) (Fax Number) ( Address) This Certificate Must Be Ntarized Subscribed and swrn t befre me this day f,, Ntary Public in and fr Cunty f State f. My Cmmissin Expires: Nevada State Cntractrs Bard (Revised 3/27/17) Page 11 f 14

14 NEVADA STATE CONTRACTORS BOARD 5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, (775) FAX (775) , INVESTIGATIONS (775) CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, (702) FAX (702) , INVESTIGATIONS (702) REFERENCE CERTIFICATE Name f Qualifying Individual: TO THE CERTIFIER: Yu must have direct knwledge f this individual s experience, and be able t certify that he r she has demnstrated a level f knwledge and skill expected f a jurneyman r better. Jurneyman is defined as a persn wh is fully qualified t perfrm, withut supervisin, wrk in the classificatin in which he r she is applying, r has successfully cmpleted a prgram f apprenticeship apprved by the state apprenticeship cuncil, r an equivalent prgram accepted by the Bard. All prtins f this frm must be cmpleted. DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED BY THIS INDIVIDUAL AT THE LEVEL OF JOURNEYMAN OR BETTER. ** LIST SPECIFIC TRADES AND DUTIES ** PLEASE TYPE OR PRINT IN INK The abve-stated wrk was perfrmed frm / / t / / Full-time Part-time (If part-time specify ttal # f years and/r mnths ) Check the bx that identifies the level that this individual wrked at while perfrming the trade(s) r craft(s) listed abve. Jurneyman Freman Supervisr Cntractr Check the bx that identifies yur business relatinship t this individual, at the time the experience was gained by them. Emplyer Unin Representative Building Inspectr Engineer Architect Cntractr Supervisr Other, specify relatinship IMPORTANT: Yu may be requested t prvide dcumentatin t verify all experience t which yu are attesting. Fr yur recrds, it is suggested that yu keep a cpy f the certificate(s) yu have cmpleted. I certify that I have direct knwledge f the wrk cvering the perid utlined abve. I certify under penalty f perjury t the truth and accuracy f the statements and infrmatin cntained herein. Number: State: (Signature f the Certifier) (Cntractr s license number and state, if applicable) (Print name) (Cmpany r business yu are affiliated with) (Address ) (City) (State) ( Zip) ( ) ( ) (Daytime Telephne Number) (Fax Number) ( Address) This Certificate Must Be Ntarized Subscribed and swrn t befre me this day f,, Ntary Public in and fr Cunty f State f. My Cmmissin Expires: Nevada State Cntractrs Bard (Revised 3/27/17) Page 12 f 14

15 NEVADA STATE CONTRACTORS BOARD 5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, (775) FAX (775) , INVESTIGATIONS (775) CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, (702) FAX (702) , INVESTIGATIONS (702) REFERENCE CERTIFICATE Name f Qualifying Individual: TO THE CERTIFIER: Yu must have direct knwledge f this individual s experience, and be able t certify that he r she has demnstrated a level f knwledge and skill expected f a jurneyman r better. Jurneyman is defined as a persn wh is fully qualified t perfrm, withut supervisin, wrk in the classificatin in which he r she is applying, r has successfully cmpleted a prgram f apprenticeship apprved by the state apprenticeship cuncil, r an equivalent prgram accepted by the Bard. All prtins f this frm must be cmpleted. DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED BY THIS INDIVIDUAL AT THE LEVEL OF JOURNEYMAN OR BETTER. ** LIST SPECIFIC TRADES AND DUTIES ** PLEASE TYPE OR PRINT IN INK The abve-stated wrk was perfrmed frm / / t / / Full-time Part-time (If part-time specify ttal # f years and/r mnths ) Check the bx that identifies the level that this individual wrked at while perfrming the trade(s) r craft(s) listed abve. Jurneyman Freman Supervisr Cntractr Check the bx that identifies yur business relatinship t this individual, at the time the experience was gained by them. Emplyer Unin Representative Building Inspectr Engineer Architect Cntractr Supervisr Other, specify relatinship IMPORTANT: Yu may be requested t prvide dcumentatin t verify all experience t which yu are attesting. Fr yur recrds, it is suggested that yu keep a cpy f the certificate(s) yu have cmpleted. I certify that I have direct knwledge f the wrk cvering the perid utlined abve. I certify under penalty f perjury t the truth and accuracy f the statements and infrmatin cntained herein. Number: State: (Signature f the Certifier) (Cntractr s license number and state, if applicable) (Print name) (Cmpany r business yu are affiliated with) (Address ) (City) (State) ( Zip) ( ) ( ) (Daytime Telephne Number) (Fax Number) ( Address) This Certificate Must Be Ntarized Subscribed and swrn t befre me this day f,, Ntary Public in and fr Cunty f State f. My Cmmissin Expires: Nevada State Cntractrs Bard (Revised 3/27/17) Page 13 f 14

16 RESUME OF EXPERIENCE (READ INSTRUCTIONS REGARDING EXPERIENCE REQUIREMENTS AND RESUME ON PAGE 3 BEFORE COMPLETING THIS FORM. USE ADDITIONAL FORMS AS NEEDED.) EXPERIENCE RECORD OF: (Print name f qualified individual) Emplyer s Name: Address: Phne N. ( ) Fax N. ( ) Address. Date f Emplyment: Frm / / T: / / Full-time Part-time (If part-time specify aggregate ttal Yrs. Ms.) Check all jb psitins held fr this emplyer Jurneyman Freman Supervisr Cntractr Self Emplyed Other, specify DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED Emplyer s Name: Address: Phne N. ( ) Fax N. ( ) Address. Date f Emplyment: Frm / / T: / / Full-time Part-time (If part-time specify aggregate ttal Yrs. Ms.) Check all jb psitins held fr this emplyer Jurneyman Freman Supervisr Cntractr Other, specify DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED Emplyer s Name: Address: Phne N. ( ) Fax N. ( ) Address. Date f Emplyment: Frm / / T: / / Full-time Part-time (If part-time specify aggregate ttal Yrs. Ms.) Check all jb psitins held fr this emplyer Jurneyman Freman Supervisr Cntractr Other, specify DESCRIBE IN DETAIL THE TYPE OF WORK PERFORMED Nevada State Cntractrs Bard (Revised 3/27/17) Page 14 f 14