Home Inspector Renewal {SFN 58339}

HOME INSPECTOR RENEWAL SECRETARY OF STATE SFN 58339 (04-2018) For Office Use Only ID Number: WO Number: Filed: By: Secretary of State State of North Dakota 600 E Boulevard Ave Dept 108 Bismarck ND 58505-0500 Telephone: (701) 328-3665 Toll-Free: (800) 352-0867, option 4 Fax: (701) 328-1690 Website: sos.nd.gov FEE: $50.00 DEADLINE: JUNE 30 By law, the envelope containing the renewal must be postmarked on or before June 30 to be considered timely filed. If June 30 falls on a Saturday, Sunday, or holiday, a postmark on the next business day is considered to be timely. Instructions: 1.For reference, see North Dakota Century Code, Chapter 43-54.2.Please type or print, complete all blanks, and enter "none" when appropriate.Additional Requirements: The renewal for a home inspector must be accompanied by: A copy of errors and omissions coverage in effect for the duration of the registration period in the amount of $100,000 or more covering all home inspection activities. Privacy: Disclosure of the social security number is required pursuant to 42 U.S.C. 666 (a)(13) and N.D.C.C. ch. 43-50 and may be used for data-matching with other state agencies. It is also used by the Secretary of State to accurately maintain home inspector records and to facilitate the process. Failure to provide one will result in the rejection of the registration. The social security number will not be released to the public. Disclosure of an email address is voluntary. Failure to provide one will not result in the rejection of the registration. The email address will not be released to the public. Name Social security number Address City State ZIP code Business name Website Email Address Business telephone number Are you 18 years or age or older? Yes No I, the undersigned applicant, am 18 years of age or older, and I declare and affirm under the penalties of perjury that the documents submitted with this application are true and correct. Signature of applicant Date American LegalNet, Inc. www.FormsWorkFlow.com SFN 58339 (04-2018)Page 2 of 2CREDIT CARD PAYMENT AUTHORIZATION SECRETARY OF STATE SFN 51478 (02-2016) WO Number (For Office Use Only): Amount . Name Telephone Number Address City State ZIP Code Card Type Visa MasterCard Discover American Express Signature (required by credit card companies) Account Number CSC Number* Card Expires (MMYY) Date*Three-digit (Visa, MasterCard, or Discover) or four-digit (American Express) security code American LegalNet, Inc. www.FormsWorkFlow.com