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2. 
4. Your Name*
5. Email Address*
7. Company Name*
8. Company Address*
10. City*
11. State*
12. Zip Code*
13. Phone Number (include dashes)*
15. Certification

    If you have a certification up load a proof here.

    If you do not have certification and have not been licensed through the City of Winona Fire Department previously you will need to take the corresponding exam before you can receive a licenses certificate. 

17. Type of Certificate License*
    -- Select One --Public License ($150)Extinguisher Special License ($20)Extinguisher Certificate ($20)Extinguishing System Certificate ($20)

    Please select the type of certificate you are applying for. 

18. Type of Certificate License*
    -- Select One --NAPublic License ($150)Extinguisher Special License ($20)Extinguisher Certificate ($20)Extinguishing System Certificate($20)

    If you need a second certificate select it here otherwise select NA.

19. Type of Certificate License*
    -- Select One --NAPublic License ($150)Extinguisher Special License ($20)Extinguisher Certificate ($20)Extinguishing System Certificate ($20)

    If you need a third certificate select it here otherwise select NA

21. Acknowledgement*

    By checking this box, I understand that this license is valid for one calendar year from January 1st until December 31st and that I will need to apply for a new license every year thereafter. 

    1. I agree.
23. Acknowledgement*

    By checking this box, I understand that this is only an application for a license certificate. I understand that I will not receive the license certificate until the invoice is paid in full and I will receive the license certificate in the email I provided. 

    1. I agree.
25. Payment Agreement*

    By Checking this box, I understand that I will receive an invoice sent to the email provided and when I receive this invoice I agree to call and make a payment by phone to the City of Winona finance department at 507-457-8262 in reference to the invoice number and I understand that I will not receive a license until the invoice is paid in full. 

    1. I agree.
27. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature*
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field