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111 N 3rd Street					                      Telephone:  660-885-8193           
Clinton, MO 64735                                                                                         FAX:  660-885-7744
 
HENRY COUNTY INSTALLER REGISTRATION APPLICATION
Note: All septic installations in Henry County MO require a permit.

Registration Fee:  $100.00      Date:____________________

Name:_____________________________________________________

Company Name:_____________________________________________ 

MailingAddress:________________________________________________________

Phone # :Home:__________ Work:___________ Mobile:_____________

Years of experience:_______ State Registration # ___________________

By completing this form, you are allowed to install septic systems in Henry County, MO. I understand and agree that I must install all septic systems in accordance with County regulations.

Four requirements for Henry County registration are:
1.       $100.00 fee
2.	Mandatory annual training class
3.	Missouri Registration

The items 1-4 are necessary to maintain current registration. If the above requirements are not maintain your name will be removed from approved installers list.

Signature:_________________________________________________