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<br />. <br /> <br /> <br />REGISTRATION APPLICATION <br /> <br /><City Name> Department 01 Public Worl<s <br />Address <br />Phone: Fax: E-MaIl: <br />Web SIte: <br /> <br />e <br /> <br />If you cbecked other in ReglslratlOll Type pI...... explain below <br /> <br />Nam_ <br />ddr... <br /> <br /> <br />City <br /> <br />5tal._ <br /> <br />Name <br /> <br />Addu.. <br /> <br />Clly <br /> <br />Stal. <br /> <br />Zip Cod_ <br /> <br />e <br /> <br />Phon. Numb.r <br /> <br />F:,x Numb.r <br /> <br />E.MaU Addr... <br /> <br /> <br />Nam. <br /> <br />Phon. Number <br /> <br />pag.r <br /> <br />Fax Numb.r <br /> <br /> <br />Please attach copies 01 certificates and licenses as requIred lor registration <br /> <br />1) CG,rtIficale 01 Insurance <br />2) CGrtlficate 01 Incorporation (1IIncorportated) <br />3) CGrtlficate 01 Authority Irom Minnesota Public UUltles Commlslon (MPUC) <br />4) Removal Bond (Equipment Owner Only) <br />5) Mlmesota Conlractcrs License <br /> <br /> <br />Oat. r.c.t....d <br /> <br />Data Ap,provad <br /> <br />. <br /> <br />. . RalllatraUon Number ......Ignad <br /> <br />Ragla.ar.d by Whom <br /> <br />3/5197 <br /> <br />24 <br />