ARKANSAS WATER WELL CONTRACTOR LICENSE APPLICATION by 8hjrtwg

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									       ARKANSAS WATER WELL CONTRACTOR LICENSE APPLICATION

   INSTRUCTIONS: Please use a typewriter to complete this form. Provide all the information requested. When completed, attach the Water Well
 Contractor Bond Form (with Power of Attorney from Surety, if required) and copies of your checks for Fees for your Contractor License ($350 DRILL
   AND PUMP, $175 DRILL ONLY, $175.00 PUMP ONLY) and Rig Permits ($145.00/permit). Make checks payable to the Arkansas Water Well
  Construction Commission and mail to Arkansas Water Well Construction Commission, 101 E. Capitol, Suite 350, Little Rock, AR 72201. The first
    phone number you list will be the number listed in the list of Water Well Contractors, published by the Commission and circulated to the public.
                                                  PLEASE SEND CHECKS TO:
                                                         P.O. Box 504985
                                                    St. Louis, MO 63150-4985


Business                                                                                                          Federal ID#
Name:                                                                                                             Or SSN:


Business Street Address (No P.O. Box):

Business Street Address (P.O. Box):
City:                    State                                      Zip:                                       County:


Phone # ( )        -                               Phone # (         )            -                 Phone # (         )            -
Owners Full Name(s):

(If corporation, provide name of Corp. CEO or chief stockholder)
Owner’s Mailing Address:

City:                                State:                         Zip:                        County:
Has your organization or owner of your organization ever held an Arkansas
Water Well Contractor License?                                                                                             Yes         No
                                                                                                                                                       Circle one
Has your organization or owner of your organization ever had a Water Well
Contractor License revoked or suspended?                                                                                   Yes         No
                                                                                                                                                       Circle one
List Rigs to be permitted on next page: (attach an additional sheet if necessary)

I certify that the above information is true and correct to the best of my knowledge and belief. I have read and
understand the notes on the second page of this form and other obligations found in Arkansas Code Ann. 17-
43-101 et, seq, (the Water Well Construction Act) and the Water Well Construction Code Rules and
Regulations.

Signature:                                                           Title:

Typed Name:                                                          Date:
                                 ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Office Use Only
Amount $              Receipt #            Issue Date             Contractor #
Revised 08/22/03                       FORM CL




                                  Rigs to be permitted
       Year           Make         Model           Type Rig      Serial          Office Use
                                                                Number
  Examples         Examples       Examples        Examples     Examples
       1979        Bucyrus Erie     22-W          Cable Tool       114
       1981         Portadrill       TLS          Air/Hammer    2E7789
       1992         Schramm         T300           Air/Mud        1234
       1987          Smeal           10T          Pump Hoist     77777
Revised 08/22/03




                        ARKANSAS WATER WELL CONSTRUCTION COMMISSION
                                 CONTRACTOR’S LICENSE BOND

KNOW ALL MEN BY THESE PRESENTS:                                                BOND NUMBER__________________________
THAT we_____________________________________________________________________________________________________
                                                         (Business name of water well contractor)


of____________________________________________________________________________________________________________
                                                             (Address of water well contractor)

                                                                     as principal and

______________________________________________________________________________________________________________

a corporation duly licensed to do business in the State of Arkansas, as Surety, do bind ourselves, our successors and assigns, jointly and severally to the
Arkansas Water well Construction Commission for the use and benefit of the public in the full penal sum of ___________________ Dollars
($                  ): that said Principal and any person employed by him shall well and duly comply with the provisions of the Arkansas Water Well
Construction Act, the same being Arkansas Code Ann. Volume 17 Chapter 43, and all rules and regulations pertaining to said Act.

WHEREAS, the above Principal is apply to the Arkansas Water Well Construction Commission for a License as Water Well Contractor and whereas, the
Commission will issue such license conditioned upon the filing of the bond with the Commission:

THE CONDITION OF THIS BOND IS SUCH, that, if said Water Well Contractor or any person employed by said Water Well Contractor shall for a
period beginning this_______ day of ___________, 20____, and continue until canceled as herein provided, well and truly comply with the provision of
the Arkansas Water Well
Construction Act, and with the rules and regulations thereof, then this obligation is to be void, otherwise to remain in full force and effect. It is
specifically understood and agreed by the parties to this bond that any and all persons having been damaged, by said Principal or Person in his employ, by
reason of violation of any of the provisions set out in the Arkansas Water Well Construction Act, and all rules and regulations pertaining to said Act, may
in their own name and without joining the Arkansas Water Well Construction Commission as a part, sue thereon, and join in said action as one of the
defendants the surety on this bond. However, no action may be taken against the Principal and Surety under this bond until all administrative remedies
have been exhausted with the Arkansas Water Well Construction Commission and so certified by the Commission. The condition of this bond shall be
construed as a new bond in the sum aforesaid for each year it remains in force provided, however, that the aggregate liability of the Surety under this bond
for any one or more violations of the Act by the Principal or his agents committed during each year this bond is in full force and effect shall in no event
exceed the sum of ____________________________________________Dollars, ($________                    ).

The Surety may terminate this bond by giving not less than thirty (30) days written notice of its intent, mailed to the Arkansas Water Well Construction
Commission at its office in Little Rock, Arkansas, and to the Principal at the address given above. Such termination shall not relieve the Surety and any
liability of the Princip0al for damages resulting from violations of the Water Well Construction Act, as amended and the Rules and Regulations during the
time this bond was in effect.

           WITNESS OUR HAND AND SEALS THIS _____ DAY OF ___________________, 20____________

Signature: Surety               (attach Power of Attorney)                     Signature:           Principal



Typed Name and Title:                                                          Typed Name and Title


                                          NOTARY PUBLIC OR OTHER JUDEICAL OFFICER

                            Subscribed and sworn to before me this ____ day of ________________, 200_




                              By_________________________________                        _______________________
                                                                                                    My Commission Expires
    Arkansas Water Well Construction Commission, 101 East Capitol, Suite 305 / Little Rock, AR 72201 (501) 682-3900, vers. September 20, 1993


Revised 08/22/03

								
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