City of Edina Form Center

2. Company Name*
4. DBA:
6. Primary License Holder is the person responsible for the company license with DOLI.
8. Primary License Holder Last Name*
9. Primary License Holder First Name*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Company Phone Number*
19. Primary Contact Cell Phone Number*
20. Primary Contact Email *
22. Contractor Type

    1. Building Contractor
    2. Roofing Contractor

    1. Exempt
    2. Specialty (one-trade only) [Explain below.]
24. Explain if one-trade only
28. Provide Certificate of Insurance. *
29. Provide Builder/Contractor License.*
31. Provide Company Lead Certification. *
33. Proof of Worker's Compensation Insurance Coverage:
35. Insurance Company Name
    Please do not provide the name of the insurance agent.
37. Policy Number
38. Expiration Date
40. I am not required to have workers' compensation liability coverage because:

    1. I have no employees.
    2. I am self-insured (include permit to self-insure below).
    3. I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children, and certain farm employees).
42. Upload a certificate of insurance or permit to self-insure.
44. I certify that I have provided proof of coverage or I am not required to have workers' compensation liability coverage.*

    1. I agree.
46. THE MINNESOTA DATA PRACTICES ACT requires that we inform you of your rights about the private data we are requesting on this form. Private data is available to you, but not to the public. We are requesting this data to determine your eligibility for a license from the City of Edina. Providing the data may disclose information that could cause your application to be denied. You are not legally required to provide the data, however, refusing to supply the data may cause your license to not be processed. Under M.S. 270.72, the City of Edina is required to provide the Minnesota Department of Revenue your MN Tax ID Number and Social Security Number if each license applicant. This information may be used to deny the issuance, renewal or transfer of your license if you owe the Minnesota Department of Revenue delinquent taxes, penalties or interest. The Department of Revenue may supply information with the Internal Revenue Service. In addition, this data can be shared by Edina City Staff, the State of Minnesota Driver License Section, Hennepin County Auditor, Bureau of Criminal Apprehension, Hennepin County Warrant Office and Ramsey County Warrant Office. By agreeing below, you indicate that you understand these rights. Your residence address and telephone number will be considered public data unless you request this information to be private and provide an alternative address and telephone number below.*

    1. I agree.
48. Alternate Address
49. Alternate Phone
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field