"Amusement Ride Certificate of Inspection" - Mississippi

Amusement Ride Certificate of Inspection is a legal document that was released by the Mississippi Department of Revenue - a government authority operating within Mississippi.

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Amusement Ride Certificate of Inspection
500 Clinton Center Drive, Clinton, MS 39056
Website: www.dor.ms.gov
Telephone: 601-923-7700
Email: amusementdecals@dor.ms.gov
Fax: 601-923-7188
There is a limit of twenty-five (25) rides per Application for Permit to Operate Amusement Ride and Attraction Safety. A new application and
fee will be required for additional rides.
Name under which business operates_______________________________________________________ FEIN/SSN___________________________
Owner’s Name:_________________________ Office Telephone:_____________________ Cell:___________________
Fax:_________________
Processing will NOT complete until all information is present
PLEASE PRINT CLEARLY
Ride Name
Manufacturer Name &
Serial Number
Name & Telephone of Operator
Decal Number
Year Built
(Department
Use Only)
Amusement Ride Certificate of Inspection
Inspector: I hereby certify and affirm that on the date shown below I personally performed the mechanical safety inspection of the amusement
ride(s) or structure(s) named above and found that the ride(s) or structure(s) meet the standards for coverage as required by ASTM International
Standard F770-19.
Inspection Date
Phone Number
Print Inspector’s Name
Inspector’s Signature
Amusement Ride Certificate of Inspection
500 Clinton Center Drive, Clinton, MS 39056
Website: www.dor.ms.gov
Telephone: 601-923-7700
Email: amusementdecals@dor.ms.gov
Fax: 601-923-7188
There is a limit of twenty-five (25) rides per Application for Permit to Operate Amusement Ride and Attraction Safety. A new application and
fee will be required for additional rides.
Name under which business operates_______________________________________________________ FEIN/SSN___________________________
Owner’s Name:_________________________ Office Telephone:_____________________ Cell:___________________
Fax:_________________
Processing will NOT complete until all information is present
PLEASE PRINT CLEARLY
Ride Name
Manufacturer Name &
Serial Number
Name & Telephone of Operator
Decal Number
Year Built
(Department
Use Only)
Amusement Ride Certificate of Inspection
Inspector: I hereby certify and affirm that on the date shown below I personally performed the mechanical safety inspection of the amusement
ride(s) or structure(s) named above and found that the ride(s) or structure(s) meet the standards for coverage as required by ASTM International
Standard F770-19.
Inspection Date
Phone Number
Print Inspector’s Name
Inspector’s Signature