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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*

    NOTE: E-mail hosts for some webmail accounts (including but not limited to BELLSOUTH and/or AT&T) may block e-mails generated from the City Domain. If you experience issues or do not receive a response within 5 business days, please contact your service provider for assistance.  You may want to enter a secondary e-mail address hosted by a separate domain (provider).

16. Professional Licenses for each Duly Authorized Representative

    A screen print from the licensing authority is acceptable.

17. Certificate of Liability Insurance
18. Certificate of Worker's Compensation Insurance
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field