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Application for Registration as a Certified Firm Under the Provisions of Article 10 Office of the State Fire Marshal's Regulations
This form has been modified since it was saved. Please review all fields before submitting.
(If partnership, include name of each partner under Responsible Persons Information below)
Federal Tax ID Number
Kansas Sales Tax Number
Business Phone (include area code)
Business Fax (include area code)
The applicant is
-- Select One --
If other, specify
Application is made for registration as a certified firm.
Application will not be processed until all documents have been received.
Applicant email address
All correspondence will be delivered through email, please make sure to include this.
RA - service, charge, re-charge, install, and inspect fixed extinguishing systems
RB - service, charge, re-charge, install, and inspect portable fire extinguishers
RC - hydro-static testing on non-DT cylinders such as wet or dry chemical containers
RD - service, charge, re-charge, and inspect fixed extinguishing systems
Provide proof of training and/or education
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.
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).
List Manufacturer(s) (Class RA firm)
List Manufacturer(s) (Class RD firm)
List other fixed business(s) owned by applicant where service is performed
List each individual employee who will be providing services under this license
Responsible Persons Information
List information required for each individual, owner, partner, and other responsible persons in applicant business
A. Full Name
B. Full Name
C. Full Name
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.
By typing your name and date below, you attest that the information contained herein is true and accurate.
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Receive an email copy of this form.
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