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2. Business Name
   (If partnership, include name of each partner under Responsible Persons Information below)
4. Federal Tax ID Number
5. Kansas Sales Tax Number
7. Business Address
9. City
10. State
11. Zip Code
13. Business Phone (include area code)
14. Business Fax (include area code)
16. The applicant is
    -- Select One --An IndividualA CorporationA PartnershipOther
17. If other, specify
21. Application is made for registration as a certified firm.
    Application will not be processed until all documents have been received.
23. Applicant email address
    All correspondence will be delivered through email, please make sure to include this.
25. Certification type

    1. RA - service, charge, re-charge, install, and inspect fixed extinguishing systems
    2. RB - service, charge, re-charge, install, and inspect portable fire extinguishers
    3. RC - hydro-static testing on non-DT cylinders such as wet or dry chemical containers
    4. RD - service, charge, re-charge, and inspect fixed extinguishing systems
27. Provide proof of training and/or education
29. Provide photo copy of insurance policy or written statement from insurer showing coverage for comprehensive general liability for bodily injury and property damage, minimum coverage $500,000 for Class RA firm, minimum coverage $100,000 for Class RB and Class RC firm, and minimum coverage $1,000,000 for Class RD firm.
31. Provide written authorization from manufacturer whose products are used by the firm. Include type(s) of system(s) the firm is authorized to install or service (Class RA firm and/or Class RD firm).
33. List Manufacturer(s) (Class RA firm)
35. List Manufacturer(s) (Class RD firm)
37. List other fixed business(s) owned by applicant where service is performed
39. List each individual employee who will be providing services under this license
43. Responsible Persons Information
    List information required for each individual, owner, partner, and other responsible persons in applicant business
45. A. Full Name
46. Position/Title
48. Home Address
50. City
51. State
52. Zip Code
54. Home phone
56. B. Full Name
57. Position/Title
59. Home Address
61. City
62. State
63. Zip Code
65. Home Phone
67. C. Full Name
68. Position/Title
70. Home Address
72. City
73. State
74. Zip Code
76. Home Phone
80. Certification
    Under the penalties imposed by K.S.A. 21-3805, I declare that I have examined this application and documents submitted in support thereof, and to the best of my knowledge and belief, they are true, correct and complete. I also certify that I am familiar with Article 10 State Fire Marshal’s Regulations, KAR 22-10-1 through KAR 22-10-17.
82. By typing your name and date below, you attest that the information contained herein is true and accurate.
84. Applicant Name
85. Title
86. Date
Leave This Blank:


88. 1. Receive an email copy of this form.
89. Email address

    This field is not part of the form submission.

90. Submit

* indicates a required field