REGISTRATION # WPCR_______________
Name
of Business
_____________________________________________________________
Address
of
Business_____________________________________________________________
Phone
# _______________________________
Name
of
Owner________________________________________________________________
Address
of
Owner______________________________________________________________
Phone#___________________________________________
Type
of
Business________________________________________________________________
Parish
Occupational License
#_____________________________________________________
Proof
of Liability
Ins.____________________________________________________________
Proof
of Workmans
Comp.________________________________________________________
State
Licensed____________________________________________________________
License
Type___________________________________________________________________
I
the undersigned do hereby attest that the above information is true and valid as
of this date:
SIGNATURE
OF OWNER OR AUTHORIZED REPRESENTATIVE:
____________________________________________________
DATE:__________________
Attach
copies of all documents presented for verification.
This
registration is valid from January 1 to December 31.
ANNUAL
FEE $50.00
