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Class 8 - Installation & Service of LPG

2. Full Company Name (Include DBA)

4. Full Physical Address

6. City

7. State

8. Zip Code

10. Full Mailing Address

12. City

13. State

14. Zip Code

16. Business Telephone

18. Provide information for the primary contact person for the license

20. Name

21. Title

23. Office Phone

24. Email

26. Do all service technicians work under an individual holding a Master Plumber Block certification?
    -- Select One --YesNo

28. List all service technicians who install, maintain, or modify LP gas equipment

29. Attach list if necessary

31. 1. Name

32. Certification #

34. 2. Name

35. Certification #

37. 3. Name

38. Certification #

40. 4. Name

41. Certification #

43. 5. Name

44. Certification #

46. 6. Name

47. Certification #

49. 7. Name

50. Certification #

52. 8. Name

53. Certification #

57. Read and initial the following.

59. We have read the Kansas statutes and rules that regulate this license and will abide by them.

61. We understand that ALL employees have been trained to current NFPA 58 standards and have proof of training.

63. We understand that this license does not allow the holder to install or service LP Gas alternative fuel systems (carburetion).

65. We understand that this license does not allow the holder to sell LP Gas or LP Gas appliances or equipment.

67. We understand that ALL employees without Master Block Certification will obtain a Class 8 Installation license or work under the constant supervision of an individual holding the required Master Block Certification.

69. 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.

71. Name

72. Date

73. Title

Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field