Division of Professions and Occupations Office of Licensing—Plumbing (303) 894-7800 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Company Name Change Application WATER CONDITIONING CONTRACTOR (WC)

The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law.

To request a name change for an existing Water Conditioning Contractor registration: • • •

Complete and return this application and supporting documentation to Division of Professions and Occupations, Office of Licensing—Plumbing, 1560 Broadway, Suite 1350, Denver, CO 80202. Attach the completed Acknowledgment of Responsibility, completed by the company owner or the Colorado water conditioning principal who is responsible for all water conditioning work the company performs. Both parties must sign the Acknowledgement of Responsibility form. Print your Registration upon Approval. DORA is no longer printing and mailing wallet cards as registrations. To print your wallet card registration in its current status, login to your Online Services account at: www.colorado.gov/dora/licensing/Login. and select “Print Your License” in the left-hand menu.

Colorado Water Conditioning Contractor Registration Number: PART 1—BUSINESS INFORMATION Old Company Name: New Company Name: Enter your company name in the blocks below, one letter or character (including commas, dashes, and apostrophes) per block. Leave the block empty for a space. Your registration will be issued with the name as it appears below.

Federal Employer Identification Number (FEIN): Company Address:

PO Box, Street: City, State, Zip:

Daytime Telephone Number: (

)

E-mail Address: (This is the primary method for communication)

Company Owner/Registered Agent:

PO Box, Street: City, State, Zip: Owner’s Daytime Telephone Number: (

)

Owner’s E-mail Address: (This is the primary method for communication)

Water Conditioning Contractor Name Change

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PART 2—WATER CONDITIONING PRINCIPAL AND EMPLOYEE INFORMATION Water Conditioning Principal Registration Holder Name: Last:

First:

Colorado Water Conditioning Principal Registration Number:

Middle:

Suffix:

Expiration Date:

Number of employees (Do not include employees with at least 10% ownership in the company):

If you indicate one or more employees above, you must comply with both the state Worker’s Compensation and Unemployment laws. List the following:

Worker’s Compensation Company Name:

Policy Number:

Unemployment Insurance ID Number:

ATTESTATION OF OWNER I state under penalty of perjury in the second degree, as defined in Section 18-8-503 of the Colorado Revised Statues, that the information contained in this application is true and correct to the best of my knowledge. In accordance with § 18-8-501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute violation of the practice act. Signature of Company Owner

Date

________________________________________________________________________________________________ Owner’s Printed Name

Water Conditioning Contractor Name Change

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ACKNOWLEDGMENT OF RESPONSIBILITY WATER CONDITIONING CONTRACTOR COMPANY To be completed by the Water Conditioning Principal or company owner. Both parties must sign the completed form. Colorado Water Conditioning Contractor Company Name: Colorado Water Conditioning Contractor Registration Number:

Expiration Date:

(enter “pending” for a new company registration)

Principal Registration Holder Name: First:

Middle:

Last:

Social Security Number: *

Suffix:

Date of Birth: (mm/dd/yyyy)

Colorado Water Conditioning Principal Registration Number: I declare that I am an (check one):

Expiration Date:

owner —OR— employee of the above-named Colorado Water Conditioning Contractor company.

By checking this box, I affirm that I am actively engaged in a full time capacity, and I assume responsibility for all water conditioning work performed. I further agree that all work will be performed under my supervision, and will comply with all regulations of Title 12, Article 58, of the Colorado Revised Statutes. ATTESTATION I state under penalty of perjury in the second degree, as defined in § 18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge. In accordance with § 18-8501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute violation of the practice act. Water Conditioning Principal’s Signature

Date

_________________________________________________________________________________________________ Water Conditioning Principal’s Name Printed Company Owner’s Signature

Date

_________________________________________________________________________________________________ Company Owner’s Name Printed Statutory Authority: If a Water Conditioning Contractor loses the services of the Water Conditioning Principal, they will be allowed twenty (20) days in which to hire another Water Conditioning Principal. If another Water Conditioning Principal has not been hired during that period, the Water Conditioning Contractor registration will be placed into a “Need WC Principal Hire-Cannot Practice” status until such time as a principal has been hired, and the appropriate fee paid. * Social Security Number Disclosure: Section 24-34-107(1) of the Colorado Revised Statutes requires that every application by an individual for a license issued pursuant to the authority set forth in title 12, C.R.S., by the Department of Regulatory Agencies, shall require the applicant's social security number. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support under § 14-14-113 and § 26-13-126, C.R.S.; and locating an individual who is under an obligation to pay child support as required by § 26-13-107(3)(a)(I)(A), C.R.S. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Disclosure of your social security number is voluntary for disclosure to other state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional regulation for identification purposes only. Your social security number will not be released for any other purpose not provided for by law.

Water Conditioning Contractor—Acknowledgment of Responsibility

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