Sfn 12012 Form – Fill Out and Use This PDF

Business Name of Applicant		Business Telephone Number
Complete Mailing Address	City	State	Zip Code
E-Mail Address	Web Address

4.If the business is a GENERAL PARTNERSHIP, all partners must be listed including full name, address, city, state, zip code, and Social Security or Federal ID number of each partner. If adequate space is not provided to list all general partners, attach an additional sheet listing all others.

If the partnership uses a fictitious name, the fictitious name must be registered with the Business Division (701-328-4284).

If the business is a LIMITED LIABILITY PARTNERSHIP, all managing partners must be listed including full name, address, city, state, zip code, and Social Security or Federal ID number of each managing partner. If adequate space is not provided to list all managing partners, attach an additional sheet listing all others. The limited liability partnership must be registered with the Business Division (701-328-4284).

If the business is a CORPORATION or LIMITED LIABILITY COMPANY it must be registered with the Business Division (701-328-4284) by filing either Articles of Incorporation or Articles of Organization if a domestic organization, or Certificate of Authority if a foreign (out-of-state) organization. If the corporation or limited liability company uses a trade name, the trade name must also be registered.

If the business is a SOLE PROPRIETORSHIP which uses a trade name, the trade name must be registered with the Business Division (701-328-4284).

5. Does the applicant have a North Dakota Sales and Use Tax permit?

Yes No If yes, provide the number _____________________.

For information regarding this permit, contact the North Dakota Tax Department at 701-328-1241.

6.North Dakota Century Code, Section 43-07-04 requires an applicant to submit to the Secretary of State a statement from North Dakota Workforce Safety & Insurance that the applicant has secured satisfactory WORKERS COMPENSATION coverage. If you do not have any employees, a verification of nonemployment is required to be filed. For details, contact the Workforce Safety & Insurance, 1600 East Century Avenue Suite 1, Bismarck, North Dakota 58506, (701-328-3800) or (800-777-5033).

7.In compliance with the Federal Privacy Act of 1974, the disclosure of the social security number or Federal ID number on this form is voluntary. They are not disclosed to the public. The numbers are used by the Secretary of State to maintain accurate contractor files. Therefore, while voluntary disclosure is requested, failure to do so will not invalidate this application.

For the purpose of qualifying for a contractor's license, the applicant submits, under oath, the following information:

A. Business Type					B. Business Federal ID
Sole Proprietorship - Complete C Below	Limited Liability Company - state of origin _________				Number
General Partnership - Complete C & D Below	Corporation - state of origin _________
Limited Liability Partnership - state of origin __________
Complete C & D Below
C. Name of Owner (or General Partner or Managing Partner)				Social Security/Federal ID Number	Home Telephone Number
Complete Mailing Address		City			State		Zip Code
D. Name of General Partner (or Managing Partner)				Social Security/Federal ID Number	Home Telephone Number
Complete Mailing Address		City			State		Zip Code

8.North Dakota Century Code, Section 43-07-04 requires an applicant to file a CERTIFICATE OF INSURANCE indicating liability coverage as proof that the applicant has secured liability insurance. The certificate holder needs to be: ND Secretary of State, 600 E Blvd. Ave, Dept. 108, Bismarck, ND 58505-0500.

9.In addition to a contractor's license, you may need to obtain other licenses or permits as required by law (e.g. the State Electrical Board, the State Plumbing Board, Transient Merchant License from the Attorney General or Asbestos Abatement from the Health Department).

(continue on reverse side)

SFN 12012 (10 - 2011) Page 2

10. Do you hold a contractor license in another state?

11.The applicant's experience and/or qualifications to act in the capacity of a contractor. This may include, but is not limited to, the number of years in the business, licenses in other states, detailed explaination of what type of work is being done, training, school, and any other pertinent information.

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

b.Have there been any civil lawsuits or arbitration proceedings in which you (or a corporation, limited liability company, or partnership of which you are or were an officer or partner) were involved as a defendant in which fraud or misrepresentation was charged during the

past year?

As a Defendant

Yes

No

c.Have you or a corporation, limited liability company, or partnership of which you are or were an officer or partner, been involved in bankruptcy 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?

Yes

No

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?

13.Once the licensing process has started and the requirements are not completed or perfected within 90 days, one half of the filing fee submitted will be retained and the other half returned to the applicant.

14.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.

AFFIDAVIT

(Sign before a notary)

The Applicant, who is 18 years of age or older, whose name is ________________________________________________________________, being first

duly sworn on oath deposes and says he/she is the applicant above named, or the ______________________________________ of the corporation or a

member of the firm, association, or co-partnership which has caused said application to be filed, and that he/she is duly authorized and empowered to make

this affidavit for and on behalf of said applicant; that he/she has read the within and foregoing application and knows the contents thereof, and that the

statements therein contained are true of his/her own personal knowledge, except as to such statement therein made upon information and belief, and as to

such statements he/she believes the same to be true.

State of ______________________	Signature of Applicant
County of ____________________

The foregoing instrument was acknowledged before me this ________ day of _______________________, 20 _______.

(Notary Seal/Stamp)	Notary Public
	My Commission Expires______________________________