Form 4 "Application for Transfer of Licence (Company)" - Nova Scotia, Canada

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Download Form 4 "Application for Transfer of Licence (Company)" - Nova Scotia, Canada

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Mail this form to:
P.O. Box 1529
Halifax NS B3J 2Y4
Business Applicant Profile Information:
Business Name:
Operating Name
Canada Revenue Agency BN #:
N.S. Registry Of Joint Stock Companies #:
Business Civic Address
:
(Not PO Box)
Street #
Street Name
Unit/Suite/Apt #
City/Town/County
Province
Country
Postal Code
Business Mailing Address (If Different):
Street, P.O. Box, RR #, Site # , etc.
City/Town/County
Province
Country
Postal Code
Business Address in Nova Scotia:
Street, P.O. Box, RR #, Site # , etc.
City/Town/County
Province
Country
Postal Code
Business Contact Information:
Name
Title
Primary Phone#
Fax#
Please Note: The submission of an application with payment does not guarantee application approval
Mail this form to:
P.O. Box 1529
Halifax NS B3J 2Y4
Business Applicant Profile Information:
Business Name:
Operating Name
Canada Revenue Agency BN #:
N.S. Registry Of Joint Stock Companies #:
Business Civic Address
:
(Not PO Box)
Street #
Street Name
Unit/Suite/Apt #
City/Town/County
Province
Country
Postal Code
Business Mailing Address (If Different):
Street, P.O. Box, RR #, Site # , etc.
City/Town/County
Province
Country
Postal Code
Business Address in Nova Scotia:
Street, P.O. Box, RR #, Site # , etc.
City/Town/County
Province
Country
Postal Code
Business Contact Information:
Name
Title
Primary Phone#
Fax#
Please Note: The submission of an application with payment does not guarantee application approval
To:
Service Nova Scotia
The Elevators and Lifts Act
Nova Scotia Business Registry
APPLICATION FOR TRANSFER OF
PO Box 1529
LICENCE
Technical Safety Division
Halifax, NS B3J 2Y4
NOTE: You must attach a completed Business (or Personal) Applicant Profile Information
sheet for the new owner with this application form!
Under The Elevators and Lifts Act and the Regulations
_____________________________________________________________________________________________
(name of applicant – PLEASE PRINT)
(mailing address)
(telephone number)
as __________________________________________ applies for transfer of Licence No. _____________
Please type in if other.
*1
(specify “owner”, “tenant”, “agent” or “otherwise”
)
granted to _________________________________________________________ ____________________
(name of licensee)
(address of licensee)
(telephone number)
to operate a ______________________________________________ known as Installation No. ________
(specify “elevator”, “dumb-waiter”, “escalator”, “manlift” or etc.)
installed at
Street or Lot #
Street Name
City/Town
County
Postal Code
And makes the following statements:
* 1
1. This applicant became owner
in place of the above -named licensee on ____________________
(date)
as a result of ____________________________________________________________________
(specify circumstances such as “change of ownership”, “change of tenancy” or as the case may be)
2. To the best of my knowledge and belief
a. the maximum capacity of this Installation is ___________ pounds/kgs, ______ persons, or ______ persons
per hour, including an operator (if required):
b. this installation is in a safe condition to be operated.
3. _____________________________________ will be carrying out the regular preventive maintenance on this
(registered elevator contractor)
elevating device.
4. Herewith remittance of $66.35 for the transfer fee (Payable to the Minister of Finance).
Dated at _______________________this _______ day of ___________________
20 ____.
(name PLEASE PRINT)
(official capacity)
(signature of submitter)
* 1
Clause (r) of Section 2 of the Act reads as follows:
(r) “owner” means the person in charge of an elevating device as owner, tenant, agent or otherwise, but does not include an operator;
Please Note : The submission of an application with payment does not guarantee application approval.
Form 4
Payment Type:
Cheque
Money Order
VISA
MasterCard
American Express
Cheque or money order must be made payable to the
Credit Card Number
Exp. (mm/yy)
Minister of Finance.
All payments must be in Canadian funds.
Card Holder’s Name (as on card)
Post- dated cheques will not be accepted.
Card Holder's Signature
Amount: $
(All fees are non- refundable.)
Title:
N ame
(Please Print):
Signature:
Date:
(DD/MM/YYYY)
Contact Phone #:
Nova Scotia Business Registry
If mailing this form back to us, please return it to:
P.O. Box 1529, Halifax, NS B3J 2Y4
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