Schedule E "Installers Application Form" - New Brunswick, Canada

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Download Schedule E "Installers Application Form" - New Brunswick, Canada

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SCHEDULE - E
(Revised January 2018)
INSTALLERS APPLICATION FORM
FOR OFFICE USE ONLY
Distribution List:
Program Mgr.:
Data Manager:
This application form is to be completed by installers that have never been licensed in the province
of New Brunswick. Also, please submit the following items with the completed application form:
$110.00 application fee (cheques are to be made payable to the Minister of Finance);
copy of the certificate of insurance for your company that shows “Products and Completed
Operations” insurance coverage;
log book detailing installation experience; and,
copy of passing grade and certificate for accredited training.
Please forward this completed application form, along with the above-noted enclosures, to:
New Brunswick Department of Environment and Local Government
Authorizations Branch
(20 McGloin Street, Fredericton, NB E3A 5T8)
P.O. Box 6000
Fredericton, New Brunswick E3B 5H1
Telephone: (506) 453-7945
Fax: (506) 453-2390
Page 1 of 2
SCHEDULE - E
(Revised January 2018)
INSTALLERS APPLICATION FORM
FOR OFFICE USE ONLY
Distribution List:
Program Mgr.:
Data Manager:
This application form is to be completed by installers that have never been licensed in the province
of New Brunswick. Also, please submit the following items with the completed application form:
$110.00 application fee (cheques are to be made payable to the Minister of Finance);
copy of the certificate of insurance for your company that shows “Products and Completed
Operations” insurance coverage;
log book detailing installation experience; and,
copy of passing grade and certificate for accredited training.
Please forward this completed application form, along with the above-noted enclosures, to:
New Brunswick Department of Environment and Local Government
Authorizations Branch
(20 McGloin Street, Fredericton, NB E3A 5T8)
P.O. Box 6000
Fredericton, New Brunswick E3B 5H1
Telephone: (506) 453-7945
Fax: (506) 453-2390
Page 1 of 2
1. INSTALLER’S INFORMATION
Installer’s Name:
Address:
Postal Code:
Telephone: (
)
Email:
Signature:
Date:
2. COMPANY INFORMATION (to be completed by the employer)
Installation Company Name:
Mailing Address:
Community:
Postal Code:
Telephone: (
)
Email:
Insurance Company Name:
Insurance Policy Number:
Date of Issue:
Date of Expiry:
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