Board of Examiners for County Highway And

BOARD OF EXAMINERS FOR COUNTY HIGHWAY AND CITY STREET SUPERINTENDENTS

APPLICATION FOR SECOND CLASS A SUPERINTENDENT LICENSE

PLEASE PRINT. All information submitted on this form MUST BE LEGIBLE.

PHOTOCOPIES OR FAXES OF COMPLETED APPLICATIONS WILL NOT BE ACCEPTED.

(1) / Name
(First) / (Middle) / (Last) / (Suffix)
(2) / Social Security No. (required by Neb.Rev.Stat. 39-2306) / --
(3) / Mailing Address
Street or PO Box / City / State / Zip Code

(All licensing correspondence will be mailed to you at this address)

(4) / Email / Fax No. / () -
Daytime Telephone No(s). / () - () - () -
(5) / Type of Class A License Applied For (Use 5a or 5b):
(5a) / City Street Superintendent
(5b) / County Highway Superintendent

(6) License Number of the Class A License Currently Held (Use 6a or 6b):

(6a) / S- City Street Superintendent
(6b) / S- County Highway Superintendent

(7) License Number of the Class B License to be replaced by the Class A License (Use 7a, 7b or 7c):

(7a) / S- City Street Superintendent
(7b) / S- County Highway Superintendent
(7c) / Not Applicable (no current second license)

(8) Application Fee: $75. Attach check or money order made out to:

Board of Examiners, Department of Transportation. (Fees are not refundable.)

(9)

Signature of Applicant Date

Attach NDOT Form 289 and a check* or money order* (do not mail cash) and return this application to:

Board of Examiners for County Highway and City Street Superintendents,

c/o Nebraska Department of Transportation, P.O. Box 94759, Lincoln, NE 68509

(If delivered in person or by express service: Liaison Services Section,

Nebraska Department of Transportation, Central Headquarters, Materials and Research Building,

Room 123B, 1400 Highway 2, Lincoln, Nebraska 68502)

*Application fees are not refundable.

This application is available on the NDOT Boards-Liaison Services Section website:

http://dot.nebraska.gov/business-center/lpa/boards-liaison/bex/downloads/

NDOT Form 289 is available on the NDOT Project Development Division website:

http://dot.nebraska.gov/media/2802/ndot289.pdf

This form is authorized by Title 425, Chapter 2, Nebraska Administrative Code (425 NAC 2).

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