"Application Form for a Weighing and Measuring Device License" - New Hampshire

Application Form for a Weighing and Measuring Device License is a legal document that was released by the New Hampshire Department of Agriculture, Markets & Food - a government authority operating within New Hampshire.

Form Details:

  • Released on October 1, 2015;
  • The latest edition currently provided by the New Hampshire Department of Agriculture, Markets & Food;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Agriculture, Markets & Food.

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Tel: (603) 271-2894
Division of Weights and Measures
Fax: (603) 271-1109
Email: devices@agr.nh.gov
PO Box 2042
Concord, NH 03302-2042
Application Form for a Weighing and Measuring Device License
Instructions
This form is to be used for all new accounts and any account updates pertaining to business contact / billing information.
Copies of your Placed-In-Service Reports MUST be submitted with this application. Your application will not be
processed if you fail to supply copies of the Placed-In-Service Reports. (Keep a copy for your records)
Placed-In-Service Reports are records showing that a Registered NH Service Technician has inspected and certified your
devices. Inspection and certification is required annually.
Return this completed, signed application AND copies of Placed-In-Service Reports to the Division, and upon receipt we
will send you an invoice.
Check one of the boxes below
Placed in Service Reports copies included?
 New Applicant/Business:
Yes:
No:
If no, explain why:
 Existing Account Holder with Changes to Contact Information:
 Existing Account with Change of Ownership:
Physical Location of Business
Billing / Payment Information
1. Opening Date: _____________________
1. Business Name: _______________________________________
2. Business Name: _______________________________________
2. Contact Person:________________________________________
3. Applicant’s Name:_____________________________________
3. Billing Address:________________________________________
4. Contact Person:________________________________________
4. City:_______________________ State: ___ Zip Code: _______
5. Physical Address: ______________________________________
5. Ph. No.:____________________ Cell Ph: __________________
6. City:_______________________ State: ___Zip Code: _______
6. Fax No.:____________________
7. Previous W&M Acct. No. (if any):_________________________
7. Email Address:________________________________________
8. Ph. No.:____________________ Cell Ph:__________________
8. Would you like the license sent by email?
9. Fax No.:____________________
Yes
No
10. Email Address:________________________________________
Questions about device licensing or this form?
Email: devices@agr.nh.gov or Call: (603) 271-2894
Please read, sign, and date:
I certify the following: (1) that all devices being used commercially are provided with this application; (2) that there are no willful misrepre-
sentations or falsifications in the information provided on or with this application; (3) that I understand that if an investigation discloses any
willful misrepresentations or falsifications, my application shall be rejected; (4) that if, after issuance of my device license, should an investi-
gation disclose any willful misrepresentations or falsifications, my license may be revoked or suspended and I may be subject to penalties un-
der RSA 438:40.
Signature of Applicant____________________________________________________
Date:________________________________
October 2015
Tel: (603) 271-2894
Division of Weights and Measures
Fax: (603) 271-1109
Email: devices@agr.nh.gov
PO Box 2042
Concord, NH 03302-2042
Application Form for a Weighing and Measuring Device License
Instructions
This form is to be used for all new accounts and any account updates pertaining to business contact / billing information.
Copies of your Placed-In-Service Reports MUST be submitted with this application. Your application will not be
processed if you fail to supply copies of the Placed-In-Service Reports. (Keep a copy for your records)
Placed-In-Service Reports are records showing that a Registered NH Service Technician has inspected and certified your
devices. Inspection and certification is required annually.
Return this completed, signed application AND copies of Placed-In-Service Reports to the Division, and upon receipt we
will send you an invoice.
Check one of the boxes below
Placed in Service Reports copies included?
 New Applicant/Business:
Yes:
No:
If no, explain why:
 Existing Account Holder with Changes to Contact Information:
 Existing Account with Change of Ownership:
Physical Location of Business
Billing / Payment Information
1. Opening Date: _____________________
1. Business Name: _______________________________________
2. Business Name: _______________________________________
2. Contact Person:________________________________________
3. Applicant’s Name:_____________________________________
3. Billing Address:________________________________________
4. Contact Person:________________________________________
4. City:_______________________ State: ___ Zip Code: _______
5. Physical Address: ______________________________________
5. Ph. No.:____________________ Cell Ph: __________________
6. City:_______________________ State: ___Zip Code: _______
6. Fax No.:____________________
7. Previous W&M Acct. No. (if any):_________________________
7. Email Address:________________________________________
8. Ph. No.:____________________ Cell Ph:__________________
8. Would you like the license sent by email?
9. Fax No.:____________________
Yes
No
10. Email Address:________________________________________
Questions about device licensing or this form?
Email: devices@agr.nh.gov or Call: (603) 271-2894
Please read, sign, and date:
I certify the following: (1) that all devices being used commercially are provided with this application; (2) that there are no willful misrepre-
sentations or falsifications in the information provided on or with this application; (3) that I understand that if an investigation discloses any
willful misrepresentations or falsifications, my application shall be rejected; (4) that if, after issuance of my device license, should an investi-
gation disclose any willful misrepresentations or falsifications, my license may be revoked or suspended and I may be subject to penalties un-
der RSA 438:40.
Signature of Applicant____________________________________________________
Date:________________________________
October 2015