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C:\Users\bparkins\AppData\Roaming\Track-It!\IS-HELPDESK\FileAttachmentsCache\IncidentRepository\dee8d9bf-9e55-4b1b-acf6-08706bca58e3\Application for Tree Service Certification or License.doc APPLICATION FOR TREE SERVICE CONTRACTOR’S LICENSE AND/OR TREE WORKER CERTIFICATION LICENSE/CERTIFICATION NUMBER Name: Phone: Address: Firm Name and Address: Check here if you would like to have your business and phone number listed on the City’s website. Email Address: International Society of Arboriculture Certified Arborist? Certification APPLYING FOR: (check one) [ ] Tree Service Contractor's License to engage in the business of tree service in the City of Moscow during Calendar Year (Include $25 check payable to City of Moscow.) [ ] Tree Worker Certification, to perform technical arboricultural services in the City of Moscow during Calendar Year [ ] Both Tree Service Contractor's License and Tree Worker Certification in the City of Moscow during Calendar Year (Include $25 check payable to City of Moscow.) I understand that all work accomplished under this license or certification must comply with the provisions of the City of Moscow's Community Forestry Ordinance and the Arboricultural Specifications and Standards Guide. I understand that failure to comply with these regulations may result in the loss of Tree Service License, Tree Worker Certification and/or a fine. Should this license or certification be suspended or revoked, I understand that I have the right to appeal as outlined in the Community Forestry Ordinance. I certify that my statements in this application are true, complete and correct to the best of my knowledge and belief. Signature Date Return completed form and any required fees to the Hamilton Indoor Recreation Center, 1724 East F St. or mail to: Moscow Parks and Recreation, P.O. Box 9203, Moscow, ID 83843. Call (208) 883-7100 for questions. FOR OFFICE USE ONLY: Liability insurance expires: City of Moscow listed as Additional Insured: [ ] Yes [ ] No Worker's Compensation Insurance: [ ] Yes Expires: [ ] N/A (can only be waived if no employees) Date Card Issued: Date Card Expires: Certification Exam Scores: Laws and General Knowledge___________ (Not required if ISA Certified Arborist) Pass/Fail Tested by Date Fees Paid: License Date Tested License: [ ] Granted [ ] Denied Certification: [ ] Granted [ ] Denied ADMINISTRATOR'S SIGNATURE ---PAGE BREAK--- C:\Users\bparkins\AppData\Roaming\Track-It!\IS-HELPDESK\FileAttachmentsCache\IncidentRepository\dee8d9bf-9e55-4b1b-acf6-08706bca58e3\Application for Tree Service Certification or License.doc Revised October 2017