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 Revision/Transfer Application for Individuals
For All Types of Fire Sprinkler Licenses
This form should be completed for RMEs who are requesting a license under a registered firm other than that shown on their license or who are changing employment status at their current firm, or who wish to change their type of RME 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	CODE	
	Transfer from one firm to another.  (Attach surrendered license.)	$ 35.00	573-04	
	State name of company transferring from:   				
	Additional license under another firm.	$ 35.00	573-04	
	Add RME – Dwelling in addition to current RME – General license.
The $35 fee can be paid after successful completion of the seminar and exam.	$50 exam fee plus $35	573-05
573-04	
	Change in full-time/part-time employment status.	No fee		

TO BE COMPLETED BY RESPONSIBLE MANAGING EMPLOYEE (RME)	
last name	first name and middle name	home are code and telephone	
			
home address	city	state	zip code	
				
county	license number	e-mail address for notification purposes (optional)
	
	RME-		
effect date of change	If you are a professional engineer registered in Texas, attach current proof of registration.	
		
I will be a    full-time employee               part-time employee of the firm named below, working _____ hours per week.	
signature of individual licensee	date	

TO BE COMPLETED BY EMPLOYER	
I certify that this applicant will be a     full-time employee           part-time     employee and will represent this firm upon licensing, subject to Article 5.43-3 of the Texas Insurance Code and the Fire Sprinkler 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 any attachments is 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 sprinklercertificate of registration no.	
	SCR-	
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.	512-305-7934
	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.