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2. All Private Provider organizations must register with the City of Jacksonville Beach and shall be responsible for keeping their information continuously maintained.

4. Registration Type*

   1. New
   2. Renewal
6. Private Provider Firm Name*
8. Private Provider Business Address*
9. Same Mailing Address?*

   1. Yes
   2. No
11. Private Provider Mailing Address
13. Office Phone Number*
14. Office E-Mail Address*
16. Private Provider Licenses
17. Resume
18. Qualification Statements
20. Professional Licenses for each Duly Authorized Representative

    A screen print from the licensing authority is acceptable.

22. Certificate of Liability Insurance
23. Certificate of Worker's Compensation Insurance
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field