Form FDACS-03580 "Lp Gas Category III Cylinder Exchange Operator License Application" - Florida

Form FDACS-03580 or the "Lp Gas Category Iii Cylinder Exchange Operator License Application" is a form issued by the Florida Department of Agriculture and Consumer Services.

Download a fillable PDF version of the Form FDACS-03580 down below or find it on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-03580 "Lp Gas Category III Cylinder Exchange Operator License Application" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Check or Money Order
payable to FDACS and remit with
form to:
LP GAS CATEGORY III
CYLINDER EXCHANGE OPERATOR
FDACS
LICENSE APPLICATION
P.O. Box 6700
ADAM H. PUTNAM
Tallahassee, Florida 32314-6700
COMMISSIONER
Chapter 527, Florida Statutes
Select one:
____ 1 year license ($65)
____ 2 year license ($130)
____ 3 year license ($195)
TO APPLY: Fill this form out completely (PRINT OR TYPE) and return it with all attachments, including the license
application fee, to the Bureau of Compliance (850) 921-1600 at the address in the upper right-hand corner.
Business Name or DBA
: Federal Employer ID Number
:
(Name to be printed on license)
(FEIN)
Physical Address
:
Mailing Address
:
(Address of business to be licensed)
(if different)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
Company Name or Corporation:
Company Mailing Address:
City, State, Zip:
Proof of Insurance or Bond must be enclosed with this application. Minimum insurance of $300,000 bodily injury
liability and property damage liability is required.
Gas Supplier Company Name and Address:
Gas Supplier License #:
Name:
Gas Supplier Phone #:
Address:
PRINT NAME OF OWNER OR MANAGER:
NAME OF PERSON PREPARING APPLICATION:
SIGNATURE OF OWNER OR MANAGER:
PREPARER’S PHONE
PREPARER’S EMAIL ADDRESS:
NO:
PREPARER’S TITLE OR OFFICE HELD:
DATE OF APPLICATION:
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 002102
FDACS-03580 08/18
Florida Department of Agriculture and Consumer Services
Division of Consumer Services
Make Check or Money Order
payable to FDACS and remit with
form to:
LP GAS CATEGORY III
CYLINDER EXCHANGE OPERATOR
FDACS
LICENSE APPLICATION
P.O. Box 6700
ADAM H. PUTNAM
Tallahassee, Florida 32314-6700
COMMISSIONER
Chapter 527, Florida Statutes
Select one:
____ 1 year license ($65)
____ 2 year license ($130)
____ 3 year license ($195)
TO APPLY: Fill this form out completely (PRINT OR TYPE) and return it with all attachments, including the license
application fee, to the Bureau of Compliance (850) 921-1600 at the address in the upper right-hand corner.
Business Name or DBA
: Federal Employer ID Number
:
(Name to be printed on license)
(FEIN)
Physical Address
:
Mailing Address
:
(Address of business to be licensed)
(if different)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
Company Name or Corporation:
Company Mailing Address:
City, State, Zip:
Proof of Insurance or Bond must be enclosed with this application. Minimum insurance of $300,000 bodily injury
liability and property damage liability is required.
Gas Supplier Company Name and Address:
Gas Supplier License #:
Name:
Gas Supplier Phone #:
Address:
PRINT NAME OF OWNER OR MANAGER:
NAME OF PERSON PREPARING APPLICATION:
SIGNATURE OF OWNER OR MANAGER:
PREPARER’S PHONE
PREPARER’S EMAIL ADDRESS:
NO:
PREPARER’S TITLE OR OFFICE HELD:
DATE OF APPLICATION:
F&A Use Only
Org Code: 42 10 06 25 000
EO: A2
Object Code: 002102
FDACS-03580 08/18
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