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

LICENSE APPLICATION FOR INDIVIDUALS
 ALL TYPES OF FIRE EXTINGUISHER LICENSES
	
This application must be accompanied by all documents and information required by Article 5.43-1 of the Texas Insurance Code and the Fire Extinguisher Rules, AND THE ORIGINAL SCORE REPORT RECEIVED FROM THOMSON PROMETRIC SHOWING A PASSING SCORE FOR THE REQUIRED EXAMS.
Complete answers must be given to all questions.
Please print or type.
Any fraudulent representation on this application may 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.
LICENSE	
CHECK ONE	TYPE OF LICENSE	LICENSE FEE	CODE	DO NOT SUBMIT THIS APPLICATION UNTIL ALL TEST REQUIREMENTS HAVE BEEN MET.	
	Type B:  for the portable fire extinguisher business only	$70	571-04		
	Type R:  for pre-engineered fixed residential range top fire extinguisher systems excluding planning	$70	571-11		
	Type K:  for portable fire extinguisher and kitchen cooking system business excluding planning (must have previously
held a Type B license or an Apprentice permit for a minimum of six months)	$70	571-10		
	Type A:  for portable fire extinguisher, fixed fire extinguisher system and kitchen cooking system business excluding planning (must have previously held a Type B license or an Apprentice permit for a minimum of six months)	$70	571-08		
	Type PL:  for portable fire extinguisher and fixed fire extinguisher system business including system planning	$70	571-09		

APPLICANT	
last name	first name and middle name	home area code and telephone	
			
home address	city	state	zip code	
				
e-mail address for notification purposes (optional)	web site address (optional)	
		
county	driver’s license number and state	social security number	date of birth	
				
weight	height	sex	color of hair	color of eyes	
					
APPLICANT'S EMPLOYER	
name of firm	area code and telephone	
		
fire extinguisher certificate of registration number (or “new application pending”)	date of hire	county	
ECR-			
address of firm	city	state	zip code	
				
QUESTIONS	
1	Have you completed National Institute for Certification in Engineering Technologies (NICET) examination requirements for certification at Level III for Special Hazard Systems Layout?
If yes, attach a copy of NICET's notification letter confirming successful completion.	YES
	NO

QUESTIONS (continued)	
2	Are you a professional engineer registered in Texas? If yes, attach current proof of registration.	YES
	NO
	
3	Do you hold a current license or permit issued by the Texas State Fire Marshal?
If yes, print license number(s) here.	YES
	NO
	
4	Have you ever held a license or permit issued by the Texas State Fire Marshal that is not shown in question 3?	YES
	NO
	
5	Have you ever had a permit or license denied, suspended, or revoked?
If yes, give details on a separate sheet and attach it to this application.	YES
	NO
	
6	Have you ever been convicted of a misdemeanor or a felony (including any pending adjudication)?
If yes, give details on a separate sheet and attach it to this application.	YES
	NO
	
RESIDENCE HISTORY	
Have you resided in any other state besides Texas, or foreign country, in the last 10 years?     YES     NO   If yes, list other states and/or countries.	
	
Please attach your criminal history report from any state other than Texas where you lived for a total of six months or more.  The report should be a current statewide report showing that a search for misdemeanor and felony convictions was made and giving the results of that search.  Our office can provide information about specific state requirements and agencies to contact.  If you were on active duty with the United States military when you lived outside of Texas, it may be possible for you to submit a copy of your military discharge, DD Form 214, MEMBER-4 copy showing honorable service, instead of the state reports.	
SIGNATURES	
In applying for a fire extinguisher license, I certify that I will comply with Article 5.43-1 of the Texas Insurance Code and the Fire Extinguisher Rules.
By my signature, I verify that the information on the 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.	
signature of individual applicant	date	
		
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 5.43-1 of the Texas Insurance Code and the Fire Extinguisher 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.	
signature of authorized representative of firm	date	
		
printed name	title	

NEXT PAGE MUST BE COMPLETED FOR TYPE A & K LICENSE APPLICANTS.

Check or money order should be made payable to the TEXAS DEPARTMENT OF INSURANCE.
Mail this completed application along with the 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
	P. O. Box 149221		Austin, TX  78701
	Austin, TX  78714-9221	Telephone No.	512-305-7934
		Fax No.	512-305-7922
		Web Site Address:	www.tdi.state.tx.us/fire/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.

THIS  PAGE  IS  TO  BE  COMPLETED  FOR  TYPE  A & K LICENSE  APPLICANTS  ONLY.

	I certify that this applicant is competent to install or service the following fixed systems, which my firm is currently qualified to install or service:

MANUFACTURER/BRAND NAME	
SYSTEM  TYPE	

		

		

NAME OF FIRM	
	
SIGNATURE OF AUTHORIZED REPRESENTATIVE OF FIRM	DATE	

PRINTED NAME	TITLE	

This statement may be supported by documentation from manufacturers of pre-engineered fixed systems or fixed system equipment relative to the applicant's receipt of training and education regarding the installation and service of these products.
Copies of other evidence of completion of a structured training program may also be submitted.