Texas Department of Insurance
State Fire Marshal’s Office Mail Code 112-FM
333 Guadalupe • P. O. Box 149221, Austin, Texas 78714-9221
512-305-7900 • 512-305-7922 fax • www.tdi.state.tx.us
	
Revision/Transfer Application For All Types of Fire Alarm Licenses
This form should be completed and returned to the address above with the fee for any individual who is requesting a license under a registered firm other than that shown on his or her license.
Any fraudulent representation on this form shall be cause for denial, suspension, or revocation of a license.
All fees are non-refundable, except for overpayments resulting from mistakes of law or fact.

CHECK ONE	TYPE OF CHANGE	FEE	
	Transfer from one firm to another.	$20.00	
	State name of company transferring from:   		
	Additional license under another firm.	$20.00	

TO BE COMPLETED BY FIRE ALARM LICENSEE	
last name	first name and middle name	home area code and telephone	
			
home address	city	state	zip code	
				
county	license number	e-mail address for notification purposes (optional) (Optional	effective date of change	
				
signature of individual licensee	date	

TO BE COMPLETED BY NEW EMPLOYER	
I certify that this applicant is an
	   agent, covered by the general liability insurance policy of the firm shown on this application
			or
	   employee, covered by the general liability insurance policy of the firm shown on this application
and upon receipt of a license is designated to represent this firm, subject to Article 5.43-2 of the Texas Insurance Code and the Fire Alarm Rules.
We know of no reason why the applicant should be denied a license.
By my signature, I verify that the information on this application and its attachments are true.
I understand that knowingly providing a false answer to any question or submitting false information or documents with this application may be tampering with a governmental record which is punishable under the Texas Penal Code Chapter 37, §37.10.	
name of registered firm	fire alarm certificate of registration	
	ACR-	
signature of authorized representative of firm	date	
		
printed name	title	

Check or money order should be made payable to the TEXAS DEPARTMENT OF INSURANCE
Mail this completed application along with appropriate fee and any additional documents to:

Mailing Address:	State Fire Marshal’s Office	Physical Address:	State Fire Marshal’s Office
	Mail Code 9999		333 Guadalupe Street
	P. O. Box 149221		Austin, TX  78701
	Austin, Texas  78714-9221	Telephone No.	512-305-7935
		Fax No.	512-305-7922
		Web site address:	www.tdi.state.tx.us/fire
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you.  Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information.  However, TDI may withhold information for reasons other than to protect your right to privacy.  Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect.  For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI’s Legal & Compliance Division at (512) 475-1757 or visit the Corrections Procedure section of TDI’s web page at www.tdi.state.tx.us.