Form Center

2. Full Company Name (Include DBA)
4. List all cylinder exchange cabinets and their location
5. Attach list if necessary
7. 1. Name of Business (if different)
8. Total # of Cages
10. Address
12. City
13. State
14. Zip Code
16. 2. Name of Business
17. Total # of Cages
19. Address
21. City
22. State
23. Zip Code
25. 3. Name of Business
26. Total # of Cages
28. Address
30. City
31. State
32. Zip Code
34. 4. Name of Business
35. Total # of Cages
37. Address
39. City
40. State
41. Zip Code
43. 5. Name of Business
44. Total # of Cages
46. Address
48. City
49. State
50. Zip Code
52. 6. Name of Business
53. Total # of Cages
55. Address
57. City
58. State
59. Zip Code
61. 7. Name of Business
62. Total # of Cages
64. Address
66. City
67. State
68. Zip Code
72. Read and initial the following.
74. We have read the Kansas Statutes and rules that regulate this license and will abide by them.
76. We understand that this license does not allow the holder to fill DOT cylinders.
78. We understand that only a KS Class 1 Dealer License holder can furnish DOT cylinders for the exchange.
80. 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.
82. We understand that if any accident involving this cylinder exchange program occurs, the Office of the State Fire Marshal will be notified as soon as possible.
84. We understand that each manager at the cylinder exchange cabinet location shall be provided training on basic propane handling procedures to be documented and kept at the location.
86. 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 of the State Fire Marshal or K.S.A. 55-1812 shall be cause for suspension or revocation of the license held.
88. Name
89. Title
90. Date
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92. 1. Receive an email copy of this form.
93. Email address

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94. Submit

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