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FIRE BACKFLOW DEVICE TESTER

CONTRACTOR REGISTRATION APPLICATION

Please Print Clearly

Date: _____________________________

You must attach an original letter from the Fire Sprinkler Contractor stating the individual seeking registration is

under their employment. The letter must be on company letterhead, dated and signed with a current State Fire

Marshall License specific to the Fire Sprinkler contractor. A TCEQ Backflow Preventer license, a current copy of your

Texas Driver’s License, and a copy of the calibration certification for the gauges that are being used. If multiple

gauges are used please provide the calibration certificate for each gauge. Gauges will need to be brought into the

office at the time of registration.

Fire Sprinkler Company Name: _____________________________________________________________________

Backflow Preventer License Holder Name: ____________________________________________________________

Officer of the company is the President, Vice President or CEO. License Holder is the person who holds the Texas

State Fire Backflow Preventer License. This person will be held responsible for seeing that all work being performed

under this registration is completed and in compliance with the City codes and ordinances.

Email Address: ________________________________________

Address: ________________________________City:______________________State:_____________Zip:___________

Office Number: _________________________Fax:_____________________________Cell:_______________________

________________________________________

_________________________________________

Original Signature of License Holder

Printed name of License Holder

This form must be notarized if any other person is registering for you or if you are registering by mail. If registering by

mail, you must include a self-addressed stamped envelope to receive a receipt of payment by return mail. Registration is

valid from January 1 through December 31. REGISTRATION FEE IS $100.00 PER LICENSE BEING REGISTERED.

NO RENEWAL NOTICE WILL BE SENT.

The State of Texas

County of_____________________§

BEFORE ME, the undersigned authority, on this day personally appeared ___________________________________known to me to be the

person whose name is subscribed to the foregoing instrument and, being by me the first duly sworn, upon oath declared that the statements and

capacity acted in are true and correct.

_____________________________________________

Signature

_____________________________________________

Title

Subscribed and sworn to before me, this_________day of__________________20______A.D. to certify which witness.

__________________________________________

Notary Public - Signature

City of Wylie Texas – 300 Country Club, Bldg 100, Wylie, TX 75098 –

972-516-6420

Fire Backflow Device Tester Contractor Registration Application - City Of Wylie Texas