LOUISIANA RECIPROCITY APPLICATION
Check: ___________ Date: ____________
TENNESSEE RECIPROCITY APPLICATION
License applying for: ____Electrical ____ HVAC ____Refrigeration ____Plumbing ____Hydronics
**NOTE** IN ORDER TO RECIPROCATE WITH OHIO FOR ANY OF THE TRADES LISTED ABOVE, THE APPLICANT MUST CURRENTLY HOLD A TENNESSEE LICENSE, AND had Tested OR Grandfathered with Tennessee to obtain it. (Those who obtained their Tennessee license via Reciprocity from another state, is not permitted to
Reciprocate into Ohio.) ***Approved Applicants will be required to take the Ohio Business and Law Exam.
Full Name: ______________________________________________________________________________________________
First
Last
M.I.
Street Address_______________________________________________ City: ________________________________________
State: _______________ Zip: _________________ E-mail _______________________________________________________
Home Phone (______) ______- __________ Work Phone (______) ______- ___________ Date of Birth: _____/_____/______ Tennessee Contractor License Number: ___________________________ License obtained via: Testing or Grandfathered
Tennessee Classification (circle one):
Unlimited Electrical Full CMC
CMC-A
CMC-C
Have you ever been convicted of a felony? Yes ____ No ____
Are you a US Citizen? Yes _____ No _____ or Are you a Legal Alien? Yes _____ No _____
NOTE: If approved and issued; you MUST assign your license to a "Contracting Company" as defined by ORC 4740.01. Please indicate the contracting company name and your job title below
Contractor Company Name: _________________________________________________________________________________
Company mailing Address: _________________________________________________________________________________
Phone #: (______) _______- ________
Your Job title (circle one)
Owner
Employee
Partner
**You must provide: a current Certificate of Liability Insurance form, including without limit, complete operations coverage, in the amount of at least five hundred thousand dollars. Along with 3 copies of permits that you or the contracting company pulled in the last 3 years installing the trade you are applying for.
I solemnly swear or affirm the information I have supplied on this application is complete and true to the best of my k nowledge.
Signature: ______________________________________ Print Full Name: __________________________________________
THIS APPLICATION MUST BE PROPERLY NOTARIZED
Subscribed and duly sworn before me according to law, by the above named applicant: __________________________________
This ________ day of __________________, 20 _____ in the County of ______________________ State of ________________
Nonrefundable Application fee: $25.00 (per license) Payable to: Treasurer State of Ohio
Mail To: Ohio Construction Industry Licensing Board 6606 Tussing Road, P.O. Box 4009 Reynoldsburg, Ohio 43068-9009
_______________________________________________ Signature of Notary Public
SEAL
For Board Use Only APPROVED: __________ DENIED: _____________
Ohio Construction Industry Licensing Board 6606 Tussing Road PO Box 4009 Reynoldsburg, OH 43068-9009 DIC 1550 Rev 3/2020
William Koester, Administrative Section Chairman An Equal Opportunity Employer and Service Provider
614-644-3493 Fax 614-728-1200 TTY/TDD 800-750-0750 com.dico/ocilb
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