Form FDACS-03579 "Lp Gas Category II Dispenser License Application" - Florida

Form FDACS-03579 is a Florida Department of Agriculture and Consumer Services form also known as the "Lp Gas Category Ii Dispenser License Application". The latest edition of the form was released in August 1, 2018 and is available for digital filing.

Download a fillable PDF version of the Form FDACS-03579 down below or find it on Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-03579 "Lp Gas Category II Dispenser 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 II
DISPENSER LICENSE APPLICATION
FDACS
ADAM H. PUTNAM
P.O. Box 6700
Chapter 527, Florida Statutes
COMMISSIONER
Tallahassee, Florida 32314-6700
Select one:
____ 1 year license ($400)
____ 2 year license ($800)
____ 3 year license ($1,200)
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
Company Name or Corporation:
:
(Name to be printed on license)
Physical Addresss
Company Mailing Address:
:
(Address of business to be licensed)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
Gas Supplier License #:
Supplier Company Name and Address:
Name:
Gas Supplier Phone #:
Address:
Gas Supplier Email Address:
Authorized Gas Supplier Representative:
Name:
Authorized Gas Supplier Representative Signature
PRINT NAME OF OWNER OR MANAGER:
NAME OF PERSON PREPARING APPLICATION:
SIGNATURE OF OWNER OR MANAGER:
PREPARER’S PHONE
PREPARER’S EMAIL ADDRESS:
NO:
DATE OF APPLICATION:
PREPARER’S TITLE OR OFFICE HELD:
Org Code: 42 10 06 25 000
F&A Use Only
EO: A2
Object Code: 002102
FDACS-03579 08/18
Page 1 of 2
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 II
DISPENSER LICENSE APPLICATION
FDACS
ADAM H. PUTNAM
P.O. Box 6700
Chapter 527, Florida Statutes
COMMISSIONER
Tallahassee, Florida 32314-6700
Select one:
____ 1 year license ($400)
____ 2 year license ($800)
____ 3 year license ($1,200)
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
Company Name or Corporation:
:
(Name to be printed on license)
Physical Addresss
Company Mailing Address:
:
(Address of business to be licensed)
City, State, Zip, County:
City, State, Zip, County:
Telephone:
Email Address:
(
)
Gas Supplier License #:
Supplier Company Name and Address:
Name:
Gas Supplier Phone #:
Address:
Gas Supplier Email Address:
Authorized Gas Supplier Representative:
Name:
Authorized Gas Supplier Representative Signature
PRINT NAME OF OWNER OR MANAGER:
NAME OF PERSON PREPARING APPLICATION:
SIGNATURE OF OWNER OR MANAGER:
PREPARER’S PHONE
PREPARER’S EMAIL ADDRESS:
NO:
DATE OF APPLICATION:
PREPARER’S TITLE OR OFFICE HELD:
Org Code: 42 10 06 25 000
F&A Use Only
EO: A2
Object Code: 002102
FDACS-03579 08/18
Page 1 of 2
PROOF OF INSURANCE OR BOND MUST BE ENCLOSED WITH YOUR APPLICATION AND FEE. Pursuant to Section
527.04, F.S., minimum insurance of $1,000,000 bodily injury liability and property damage liability covering the products
and operations of the business is required.
QUALIFIERS: List the names and certificate numbers of all qualifiers employed by this company below. Attach a
separate sheet if necessary. A separate qualifier is required for every 10 employees.
Indicate number of employees at this location____________
NAME
CERTIFICATE NUMBER
1.
2.
3.
4.
FDACS-03579 08/18
Page 2 of 2
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