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NOTICE OF DISASSOCIATION or QUALIFIER RESIGNATION Utah Division of Occupational and Professional Licensing 160 East 300 South P. Date of Disassociation or Resignation Name of Qualifier Trade Classification Address of Qualifier if known City State Zip Telephone Number Signature of Owner / Officer Resigning Qualifier Printed Name DOPL-FM-029 Rev 2010-09-07 Date Signed. O. Box 146741 Salt Lake City Utah 84114-6741 Telephone 801 530-6628 FAX 801 530-6511 Instructions Pursuant to the Utah Construction Trades Licensing Act 58-55-304 6 and 7 a licensed contractor is required to notify the Division in writing within 10 days after cessation of association or employment of the qualifier. If this notice is given the license shall remain in force for 60 days after the date of cessation of association or employment. The licensee shall replace the original qualifier with another individual qualifier within the 60 day period or the license shall be automatically suspended* Please furnish the requested information below. Other important information Contractor licenses are issued to the business entity Sole Proprietorship that applied for the license. The qualifier for the business entity is not the owner of the contractor license unless the qualifier was also the owner of the business entity to whom the contractor license was issued* The disassociated qualifier cannot engage in construction activities until they either apply for a license for their own business entity and the license is issued or they again become a W2 employee or officer of a licensed contractor. Limited Liability Company Corporation etc* Name of Business Entity or Licensee License Number The qualifying management employee qualifier listed below is no longer associated with this licensee. O. Box 146741 Salt Lake City Utah 84114-6741 Telephone 801 530-6628 FAX 801 530-6511 Instructions Pursuant to the Utah Construction Trades Licensing Act 58-55-304 6 and 7 a licensed contractor is required to notify the Division in writing within 10 days after cessation of association or employment of the qualifier. If this notice is given the license shall remain in force for 60 days after the date of cessation of association or employment. If this notice is given the license shall remain in force for 60 days after the date of cessation of association or employment. The licensee shall replace the original qualifier with another individual qualifier within the 60 day period or the license shall be automatically suspended* Please furnish the requested information below. The licensee shall replace the original qualifier with another individual qualifier within the 60 day period or the license shall be automatically suspended* Please furnish the requested information below. Other important information Contractor licenses are issued to the business entity Sole Proprietorship that applied for the license. Other important information Contractor licenses are issued to the business entity Sole Proprietorship that applied for the license. The qualifier for the business entity is not the owner of the contractor license unless the qualifier was also the owner of the business entity to whom the contractor license was issued* The disassociated qualifier cannot engage in construction activities until they either apply for a license for their own business entity and the license is issued or they again become a W2 employee or officer of a licensed contractor. .