Sfn 12011 Form – Fill Out and Use This PDF

License #		Class of License		Business Telephone #					Business Federal ID #	Business Type
Certificate of Liability Insurance expires on:									Renewal Fee	ND Sales and Use Tax Permit #
If expiration date is prior to date of this renewal, please provide a current certificate									$
Applicant's name as currently licensed with this office.
E-mail Address					Web Address					ND Workforce Safety & Insurance
										Account #
1.	Do you have a North Dakota Sales and Use Tax permit?					Yes	No	If yes, record the account number in the above box. For information regarding
	sales and use tax permits, contact the North Dakota Tax Department at 701-328-3470.
2.	Did you have any employees during this reporting period?					Yes	No	If yes, record the Workforce Safety & Insurance account number in the above
	box. For information regarding Workforce Safety & Insurance, contact 701-328-3800.
3.	Is the information listed above, including address, still correct?						Yes	No If no, please make corrections.
4.	Name of contact person for this report _________________________________________ Daytime Telephone # (____)_____________.

1.List the names and addresses of any companies or individuals for whom you completed a project, contract, or subcontract during the preceeding calendar year in North Dakota in excess of $25,000.00. (Reference North Dakota Century Code, Section 43-07-10.)

2.Identify the type of work completed.

3.Specify the dollar value of the work.

4.If a performance bond was required, list the name and address of the issuing company. If no performance bond was required, write "None".

		2. TYPE OF WORK	3. VALUE OF WORK	4. PEFORMANCE BOND
1. NAME	CITY, STATE	COMPLETED	COMPLETED	NAME	CITY, STATE
(Example) John Doe Co.	Bismarck, ND	Concrete Work	$25,000	None

ALL OF THE FOLLOWING QUESTIONS MUST BE ANSWERED.

6. If your answer is "YES" to any of the following questions, give the details on a separate sheet and attach to this application.

a. Has any license been denied, suspended or revoked	Yes	No
For you?
For any officer?	Yes	No
For any partner?	Yes	No
For any entity with which you, officers or
partners have any interest in or are
associated with?	Yes	No

b. Have you or a corporation, limited liability company, or partnership of which you are or were an officer or partners, been charged with a civil lawsuit in

which fraud or misrepresentation was charged or alleged?	Yes	No

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SFN 12011 (12-07) Page 2

c.Have you or a corporation, limited liability company, or partnership of which you are or were an officer or partner, been involved in or initiated bankruptcy or insolvency proceedings during the past five years?

d.Are there any judgments, arbitration awards, mechanics liens or federal or state tax liens against you, or a corporation, limited liability company, or partnership of which you are an officer or partner, in North Dakota or elsewhere?

e. Has the applicant, or officers or partners of the applicant been charged with or convicted of a felony or misdemeanor within the last five years?

7.North Dakota Century Code, Section 43-07-19 states every applicant who is not a resident of the state of North Dakota, by signing and filing the application appoints the Secretary of State as the applicant's true & lawful agent upon whom may be served all lawful process in any action or proceeding against such non-resident contractor.

The undersigned, who is 18 years of age or older, hereby certifies that all payroll taxes (including North Dakota income tax and premiums for workforce safety & insurance and unemployment insurance) due and payable on the day of this application have been submitted and that all of the information provided on the renewal application is true and complete.

Signature of Owner*, Partner, or Authorized Officer

Date

*If a sole proprietorship business structure, a spouse is not authorized to sign on behalf of the owner.

FEES:

								TOTAL PAYABLE
NEW LICENSE		CONTRACTOR LICENSE			RENEWAL FEES	PENALTY FEES		AFTER MARCH 3 AND
FEES								ON OR BEFORE JUNE 2
Fee $300.00	Class A	for contracts over	$250,000		Fee $60.00	Additional $45.00		Total	$105.00
Fee $200.00	Class B	for contracts up to	$250,000		Fee $40.00	Additional $30.00		Total	$ 70.00
Fee $150.00	Class C	for contracts up to	$	120,000	Fee $30.00	Additional $22.50		Total	$ 52.50
Fee $ 50.00	Class D	for contracts up to	$	50,000	Fee $10.00	Additional $ 7.50		Total	$ 17.50

INSTRUCTIONS:

1.The provisions for contractor licensing are found in Chapter 43-07 of the North Dakota Century Code.

2.The renewal deadline for a contractor's license is March 3, 2008. If not renewed by that date, the current contractor's license automatically expires and completing any work over $2,000 per job would be in violation of 43-07.

3.If the license renewal application is filed after the deadline, state law requires the payment of a penalty fee. This penalty fee must be submitted along with the renewal application and renewal fee at the time the late application is filed. The penalty fees are listed above.

4.Contractor license renewal applications will not be accepted after June 2, 2008. After that date, a previously licensed contractor must submit an application for a new license and pay the appropriate new contractor license fees.

5.If the pre-printed information on this renewal application is incorrect, please cross out the incorrect information and provide the correct information and initial the change.

6.By law, a contractor's license cannot be renewed unless a copy of the contractor's current certificate of liability insurance is on file with the Secretary of State's office. A new certificate is not needed if the pre-printed expiration date at the top of the front page is later than the filing date of this renewal application.

7.Questions #5 and #6 must be answered with either a yes or no. If yes, provide the requested information. Use more sheets, if necessary.

8.The renewal application must be signed by the owner, partner, or authorized officer. If the renewal application contains false information, the contractor's license is subject to revocation under the provisions of state law.

9.Checks for renewal and penalty fees must be made payable to the Secretary of State. The Secretary of State accepts VISA, Master Card, and Discover charge cards. If you wish to pay by credit card, complete the enclosed charge card authorization.

10.In addition to a contractor's license, you may need to obtain other licenses or permits as required by law (for example, including but not limited to the State Electrical Board and the State Plumbing Board).

FAX FILING: A document and Credit Card Payment Authorization may be faxed to 701-328-1690. A faxed filing does not expedite the process of the document in the office of the Secretary of State.

MAILING INSTRUCTIONS: Send the completed renewal application to:

Secretary of State

State of North Dakota

600 E Boulevard Ave Dept 108

Bismarck ND 58505-0500

Telephone: 701-328-3665 Toll Free: 800-352-0867 (ext. 8-3665) Fax: 701-328-1690 Web Page: www.nd.gov/sos/