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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