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NQTICE OF ELEC7'!ON TO BE EXEMPT <br /> lf.this a pl��afion c3ntains incomptete ar inaccurate intorma6on, i�may causa a t3eFay in the issuance of yac�r exemptic�n_An <br /> officer�lecting an exemption under Chapter 440, Flarida Statutes,is not eritilfied to benefits under this chapter. <br /> , Sectio 1: - <br /> , . <br /> APP41 ANT INFORRAATION <br /> Pirst i.ast Name: Dauglas F Ragers . <br /> State #rive�'s�icense Number: S`#ate iD Number. � State: F�' <br /> � - - ,. <br /> R2629�650330{l <br /> � Date � Birth: 9/90/9950 .. <br /> � � , <br /> Socia Security Number past four dig"rts): 5447 , <br /> Email�Add�ess: Rogers-elect�ic�hotmait.corr� <br /> Secti n 2: • . - - <br /> CONSTRUG"T'!ON INDUSTRY APPLiCANY($SO-EEE-REQUIRED) ` <br /> Office of a Carporation (Construction) <br /> �7"rtte: PRE$tDENT _ � <br /> ' �ecti�n 3: ; , :, ` <br /> 'fhis section shauSd be campleted wit�i mforrnatian specific ta y,aur corporatio�i or f+a the[icnit�ct=l`ia�iility,company in which you are <br /> , a mer�tber.The name of the corporation o�-Jirnited tiability company 1"�sted on this appticatian_MUST match th�name of the <br /> car�pa #ion or limited liabitify campany as tegiste€ed v�rith�tt�e-�loiida Divisian of Corporatiortis. <br /> �'1+N af Corporation or LLC: :Rogers Electric Incorporafed FEiN: 59-3006458 <br /> ,,,.!E YO NEED TO APP�Y FOR A FEtN,CLICiC HEf2E .. , <br /> : Businl Name(DBA}:-:Rogers Eiecfic tncorporated Phone: {352)583-56'f 9 <br /> � Appli� nYs Address.of Re+cord: 331&�Portage Path <br /> City Dade Ciiy _ State: FL. Zip 33523� CouMy: Hernando <br /> Click on tha arrow(s).next#o tFre#ext box{s}to view a iist of available 5cope classifica#ionsl#rades'For the form tYPe r�asen in <br /> Secti n;2.4''Iick on tkie appropriate-.scape�to sefect.lf you are unsur.e,as to_uyhich ciassificationflrade to choose,please contact <br /> yaur o�tc-ers;�c�i�pensation inst�ance'cariier..tfyou da nat have a usiottcei"s'cornpensafion irtsurance policy,con#act the <br /> •'Natio at.Council=on Compensa�ia��Insurance(NCCI)at 1-800-622.=4123 option 5 ta obtain a dassficafion code. <br /> S`cop�9: o00os LtCEtvSED ,-Scope 2-: � Scope 3: Scope 4: <br /> I <t EI:ECTRICAL . . <br /> f�' CQNTRACTOR <br /> .r!` -�'0114: _ <br /> :t: <br /> 'The rpora6on a#which.you are an o#f�cer or 3imited liabitrty campany of ufiich yc}ei are a�ember must be registered and in ACTlVE status <br /> witf� e Florida D'}vision'of.Corporafions.Applicants applying as an officer of a corporation must be listed as an officer of the Corporation with <br /> • the F orida Division of,Coiporations.List the documerrt number on file with the Florida Division of Carporabc�ns• <br /> ;�; = <br /> PO4._:m.0005923 <br /> ` S ��i�5: � - - � <br /> �' Pu�,'uanti�to>�Chaptelr-�489, F_S. (cantractor licensing law),list ce►tified or registered licenses related to#he scope of business or <br /> trad�tisteii�:in Section 3 held by the-applicant,::or the certified or regis#e�-+ed license numbers hetd by the qual�er for the <br /> corp�aration`ar limited i'iabii'i#y campany tis�ed on this appiication.The business name iisted an the ticense MUST match the name <br /> '� ' of the corpara�on or Gmited liabil'ity company as registered with the Flor�da D'rvision of Corporations and an this Notiae of Election <br /> to b�Exernp�. <br /> I <br /> EFt0012229 <br />� <br />