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A 50 fee applies to each additional LIMITED FIRE SPRINKLER SYSTEM LSS FIXED FIRE EXTINGUISHING SYSTEM PRE-ENGINEERED KITCHEN FFK PORTABLE FIRE EXTINGUISHERS PFE See special documentation requirements for this endorsement IS THIS APPLICATION FORM FOR YOUR HEADQUARTERS LOCATION YES NO IF NO PLEASE PROVIDE NAME LOCATION OF HEADQUARTERS OFFICE NAMES OF OFFICERS OF THE BUSINESS SIGNED DATE By signing this form I attest that all of the information above is true to the best of my knowledge and is presented under the penalties of perjury. FOR DEPARTMENT OF SAFETY USE ONLY COPY OF R.M. E. CERTIFICATE YES NO PAYMENT CHECK CHECK COPY OF CERTIFICATE OF INSURANCE YES NO CREDIT CARD AMOUNT IF CORP COPY OF CERTIFICATE OF GOOD STANDING BY SECRETARY OF STATE IF PFE COPY OF SITE INSPECTION REPORT BY NHFMO OF THE FACILITY YES DSFM 97 06/11 NO. STATE OF NEW HAMPSHIRE DEPARTMENT OF SAFETY DIVISION OF FIRE SAFETY OFFICE OF THE STATE FIRE MARSHAL 33 HAZEN DRIVE CONCORD NH 03305 603-223-4289 VOLUNTARY CERTIFICATION OF FIRE PROTECTION EQUIPMENT TECHNICIANS APP. FEE 100 RENEWAL FEE 90 ADD L ENDORSEMENT 50 FAX 603-223-4295 APPLICATION FOR FIRM CERTIFICATE OF REGISTRATION Place a check in the appropriate box in each column* TYPE ORIGINAL RENEWAL PREVIOUS CERT. IF RENEWAL PROVIDE PREVIOUS CERTIFICATE FIRM NAME FIRM MAILING ADDRESS CITY STATE ZIP FIRM PHYSICAL ADDRESS P. O. BOX IS NOT ACCEPTABLE FIRM TELEPHONE FED EMPLOYER ID FIRM E-MAIL ADDRESS NAME OF R*M. E* R*M. E* CERT R*M. E* ADDRESS LIST ADDITIONAL RME s ON THE MULTIPLE RME FORM ENDORSEMENT BEING APPLIED FOR endorsement Check only the appropriate endorsement s being applied for. A 50 fee applies to each additional LIMITED FIRE SPRINKLER SYSTEM LSS FIXED FIRE EXTINGUISHING SYSTEM PRE-ENGINEERED KITCHEN FFK PORTABLE FIRE EXTINGUISHERS PFE See special documentation requirements for this endorsement IS THIS APPLICATION FORM FOR YOUR HEADQUARTERS LOCATION YES NO IF NO PLEASE PROVIDE NAME LOCATION OF HEADQUARTERS OFFICE NAMES OF OFFICERS OF THE BUSINESS SIGNED DATE By signing this form I attest that all of the information above is true to the best of my knowledge and is presented under the penalties of perjury. FOR DEPARTMENT OF SAFETY USE ONLY COPY OF R*M. E* CERTIFICATE YES NO PAYMENT CHECK CHECK COPY OF CERTIFICATE OF INSURANCE YES NO CREDIT CARD AMOUNT IF CORP COPY OF CERTIFICATE OF GOOD STANDING BY SECRETARY OF STATE IF PFE COPY OF SITE INSPECTION REPORT BY NHFMO OF THE FACILITY YES DSFM 97 06/11 NO. STATE OF NEW HAMPSHIRE DEPARTMENT OF SAFETY DIVISION OF FIRE SAFETY OFFICE OF THE STATE FIRE MARSHAL 33 HAZEN DRIVE CONCORD NH 03305 603-223-4289 VOLUNTARY CERTIFICATION OF FIRE PROTECTION EQUIPMENT TECHNICIANS APP. FEE 100 RENEWAL FEE 90 ADD L ENDORSEMENT 50 FAX 603-223-4295 APPLICATION FOR FIRM CERTIFICATE OF REGISTRATION Place a check in the appropriate box in each column* TYPE ORIGINAL RENEWAL PREVIOUS CERT. FEE 100 RENEWAL FEE 90 ADD L ENDORSEMENT 50 FAX 603-223-4295 APPLICATION FOR FIRM CERTIFICATE OF REGISTRATION Place a check in the appropriate box in each column* TYPE ORIGINAL RENEWAL PREVIOUS CERT. IF RENEWAL PROVIDE PREVIOUS CERTIFICATE FIRM NAME FIRM MAILING ADDRESS CITY STATE ZIP FIRM PHYSICAL ADDRESS P.