Applicant Registration Form
PERSONAL DETAILS
LOGIN DETAILS
OTHER DETAILS
LICENSE(S) DETAILS
ESTABLISHMENT DETAILS
DESIGNER DETAILS
INSTALLER DETAILS
Well driller details
Individual details
PREVIEW
STEP 1- PERSONAL DETAILS
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Name
Address
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Street No.
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Street Name
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City
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State
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Zip
Contact
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Phone
Alt. Phone
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Email
Fax
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STEP 2 - LOGIN DETAILS
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UserName
Use only alpha characters and numbers. Do not use spaces, underscores, punctuations or special characters like ' , /, \ , * in the User Name or the password. The name should not exceed 20 characters.
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Password
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Re-enter Password
Upload Photo
Browse
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STEP 3- DETAILS
Instructions
Please describe yourself using the checkboxes below.
(Check all that apply.)
As you click, new sections will be added to this registration form.
Any information that you register with now will automatically flow into all applicable forms in the future.
Establishment: If you are a food service establishment, Select this option.
Individual: If you are an individual with a food service business but no physical facility, Select this option.
If you do not create an account as either installer or designer you will not receive email notification or have access to issued COC's, Plan approvals, Water supply certificates and other realted notifications without contacting the original applicant or the Alliance Health Department.
Designer: Select this option if you are an engineer or sanitarian that is applying for permits on behalf of a client.
Installer: If you are a septic installer select this option.
I am applying for permits/licences:
as an ESTABLISHMENT, RESTAURANT or FACILITY
as a SEPTIC DESIGNER
as a SEPTIC INSTALLER
as a WELL DRILLER
as a INDIVIDUAL
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STEP 4- LICENSE(S) DETAILS
Business Name
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License Type
Select License Type
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License Number
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Expiration Date
Select date
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License Type
Select License Type
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License Number
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Expiration Date
Select date
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ADD NEW LICENSE TYPE
WORKER'S COMP DETAILS
Sole proprietor
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Insurance Company Name
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Policy Number
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Policy Expiration Date
Select date
Are you an employer? Check the appropriate box
I am a employer with
employees (full and/or part-time).*
I am a sole proprietor or partnership and have no employees working for me in any capacity. [No worker's comp. insurance required.]
I am a homeowner doing all work myself. [No workers' comp. insurance required.]+
I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees.
I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have worker's comp. insurance.++
We are a corporation and its officers have exercised their right of exemption per MGL c. 152, ß 1(4) and we have no employees. [No worker's comp. insurance required.]
Uncheck
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STEP 5- ESTABLISHMENT DETAILS
Address Does Not Appear in Drop-Down
Street Address / Owner
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Est. Name
DBA
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Town Name
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Street Name
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Map Block Lot
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Street Number
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Street Name
Map Block Lot
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Street Number
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City
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State
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Zip
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Telephone
Fax
Property Owner Details
Property Owner Name
Street Number
Street Name
City
State
Zip
Telephone
Business Owner Details
Same As Property Owner
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Business Owner Name
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Street Number
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Street Name
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City
*
State
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Zip
Telephone
Email
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STEP 6- DESIGNER DETAILS
Designer Details
Same As Applicant
Septic Designer Name
Name of Company
Street Number
Street Name
City
State
Zip
Telephone
Email
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STEP 7- INSTALLER DETAILS
Installer Details
Same As Applicant
Septic Installer Name
Name of Company
Street Number
Street Name
City
State
Zip
Telephone
Email
Exp. Date
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STEP 8- Well Driller
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Well Drilling Company Name
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Well Driller Certification Number
*
Expiration Date
Select date
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STEP 9- INDIVIDUAL DETAILS
Preparer's Details
Same As Applicant
Preparer Name
Street Number
Street Name
City
State
Zip
Telephone
Email
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