Form FDACS-03583 "Lp Gas Category VI Miscellaneous Operator License Application" - Florida

Form FDACS-03583 is a Florida Department of Agriculture and Consumer Services form also known as the "Lp Gas Category Vi Miscellaneous Operator 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-03583 down below or find it on Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-03583 "Lp Gas Category VI Miscellaneous Operator License Application" - Florida

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Florida Department of Agriculture and Consumer Services
Make Check or Money Order
Division of Consumer Services
payable to FDACS and remit with
form to:
LP GAS CATEGORY VI
MISCELLANEOUS OPERATOR LICENSE APPLICATION
FDACS
P.O. Box 6700
ADAM H. PUTNAM
Chapter 527, Florida Statutes
Tallahassee, Florida 32314-6700
COMMISSIONER
Select one:
____ 1 year license ($200)
____ 2 year license ($400)
____ 3 year license ($600)
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.
APPLICATION IS HEREBY MADE FOR THE FOLLOWING LP GAS LICENSE (SELECT ONE):
Manufacturer of LP Gas Appliances and Equipment
Pipeline System Operator (Please attach names
and addresses of systems on a separate sheet)
Requalifier of Cylinders
Fabricator, Repairer and Tester of Vehicles and
Cargo Tanks
Business Name or DBA
:
(Name to be printed on license)
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:
PRINT NAME OF OWNER OR MANAGER:
NAME OF PERSON PREPARING APPLICATION:
SIGNATURE OF OWNER OR MANAGER:
PREPARER’S PHONE NO:
PREPARER’S EMAIL ADDRESS:
DATE OF APPLICATION:
PREPARER’S TITLE OR OFFICE HELD:
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.
Org Code: 42 10 06 25 000
F&A Use Only
EO: A2
Object Code: 002102
FDACS-03583 08/18
Florida Department of Agriculture and Consumer Services
Make Check or Money Order
Division of Consumer Services
payable to FDACS and remit with
form to:
LP GAS CATEGORY VI
MISCELLANEOUS OPERATOR LICENSE APPLICATION
FDACS
P.O. Box 6700
ADAM H. PUTNAM
Chapter 527, Florida Statutes
Tallahassee, Florida 32314-6700
COMMISSIONER
Select one:
____ 1 year license ($200)
____ 2 year license ($400)
____ 3 year license ($600)
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.
APPLICATION IS HEREBY MADE FOR THE FOLLOWING LP GAS LICENSE (SELECT ONE):
Manufacturer of LP Gas Appliances and Equipment
Pipeline System Operator (Please attach names
and addresses of systems on a separate sheet)
Requalifier of Cylinders
Fabricator, Repairer and Tester of Vehicles and
Cargo Tanks
Business Name or DBA
:
(Name to be printed on license)
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:
PRINT NAME OF OWNER OR MANAGER:
NAME OF PERSON PREPARING APPLICATION:
SIGNATURE OF OWNER OR MANAGER:
PREPARER’S PHONE NO:
PREPARER’S EMAIL ADDRESS:
DATE OF APPLICATION:
PREPARER’S TITLE OR OFFICE HELD:
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.
Org Code: 42 10 06 25 000
F&A Use Only
EO: A2
Object Code: 002102
FDACS-03583 08/18
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