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Get TX Backflow Assembly Tester Registration - Dallas 2015-2024

NEW BACKFLOW ASSEMBLY TESTER REGISTRATION RENEWAL Contractor MUST BE COMPLETELY FILLED OUT IN ORDER TO BE ACCEPTED FOR REGISTRATION ORIGINAL REGISTRATION The licensed Tester must personally appear at 320 E. Jefferson Room 105 and furnish 1 This original form completed 2 Their Current Backflow Tester s pocket license 3 An approved photo identification 4 Payment of 120. 00. Please make checks payable to City of Dallas. RENEWAL REGISTRATIONS May be processed in person at any Building Inspections office or on-line through the contractor s Dallas website. NEW BACKFLOW ASSEMBLY TESTER REGISTRATION RENEWAL Contractor MUST BE COMPLETELY FILLED OUT IN ORDER TO BE ACCEPTED FOR REGISTRATION ORIGINAL REGISTRATION The licensed Tester must personally appear at 320 E* Jefferson Room 105 and furnish 1 This original form completed 2 Their Current Backflow Tester s pocket license 3 An approved photo identification 4 Payment of 120. 00. Please make checks payable to City of Dallas. RENEWAL REGISTRATIONS May be processed in person at any Building Inspections office or on-line through the contractor s Dallas website. 1 All documents listed above are required for each registration renewal 2 If not registering in person this document must be notarized 3 Payment of 120. 00. Please make checks payable to City of Dallas. Please note Backflow Tester Certificates of Registration provided for in the code expire annually upon the expiration date of the State License. Pursuant to the City Code application is hereby made for registration as a Backflow Tester All Information Must Be Complete Please Do Not Use Same Backflow Tester Information Date / / State License Driver s License Contr* Expiration Date / E-mail Name of Tester Address Number Street City State Zip Mailing Address Phone Number Fax Number If company is located within the city limits of Dallas please provide the certificate of occupancy number C. O. The Licensed Backflow Tester is the only person authorized to sign permits or validations to perform backflow test. Name PIN LIMIT TO 4 DIGITS OR LESS Tester I DO DEPOSE AND SAY THE ABOVE INFORMATION IS TRUE AND CORRECT. SIGNED X Signature of Responsible License Holder Registration Clerk/Notary Public Sworn to me before this Must Be Signed by Registration Clerk or Notarized Day of Any changes or corrections to this information must be submitted on this same form and marked as amended* A 30. 00. Please make checks payable to City of Dallas. RENEWAL REGISTRATIONS May be processed in person at any Building Inspections office or on-line through the contractor s Dallas website. 1 All documents listed above are required for each registration renewal 2 If not registering in person this document must be notarized 3 Payment of 120. 1 All documents listed above are required for each registration renewal 2 If not registering in person this document must be notarized 3 Payment of 120. 00. Please make checks payable to City of Dallas. Please note Backflow Tester Certificates of Registration provided for in the code expire annually upon the expiration date of the State License. .

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