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2. Full Company Name (Include DBA)
4. List all dispenser tanks, size and location
5. Attach list if necessary
7. 1. Name of Business (if different)
8. WC Gal.
10. Address
12. City
13. State
14. Zip Code
16. 2. Name of Business
17. WC Gal.
19. Address
21. City
22. State
23. Zip Code
25. 3. Name of Business
26. WC Gal
28. Address
30. City
31. State
32. Zip Code
34. 4. Name of Business
35. WC Gal
37. Address
39. City
40. State
41. Zip Code
43. Does the company install mobile LP Gas systems?
    -- Select One --YesNo
44. If yes, attach a list of all your mobile LP Gas installers
    Include mechanical license #
48. Read and initial the following.
50. We have read the Kansas statutes and the rules that regulate this license and will abide by them.
52. We understand that this license does not allow the holder to install or service LP Gas alternative fuel systems (carburetion systems).
54. We agree to furnish the Office of the State Fire Marshal all reports as required in the Kansas Statutes Annotated and familiarize ourselves with the rules and regulations of the state of Kansas.
56. We understand that this license is non-transferable and any change in name or ownership will be reported to the Office of the State Fire Marshal.
58. We understand that this license does not allow installations of the LP gas equipment and appliances, nor does it allow handling of DOT bottles or tanks.
60. By typing my name and date below, I certify that this information is true and correct. Any false or fraudulent statement or failure to comply with the rules and regulations promulgated by the Office if the State Fire Marshal or K.S.A. 55-1812 shall be cause for suspension or revocation of the license held.
62. Name
63. Title
64. Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field