Application For License To Test And Repair Scales (Service Repairman) Form
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1
2No. ___________________
Mississippi Department of Agriculture and Commerce
P.O. Box 1609
Jackson, Mississippi 39215-1609
APPLICATION FOR LICENSE TO TEST AND REPAIR SCALES
(Service Repairman)
I hereby make application for a license to install, repair and/or test scales in the State of Mississippi as
provided by Section 75-27-67, Mississippi Code of 1972 as amended.
Name of Applicant (PLEASE PRINT)
Company Represented
Applicant Mailing Address
Telephone
City
State
Zip Code
Company Mailing Address
City
State
Zip Code
Telephone
Fax Number
I understand and affirm that: (1) License issued hereunder will allow me to install, test, adjust, repair and remove
“Condemned for Repairs” tags placed on weighing and measuring devices by Mississippi Weights and Measures
Officials, and to place in service, on a temporary basis, newly installed devices and repaired devices which have
been previously condemned until such time as an official inspection can be made by Mississippi Weights and
Measures Officials. (2) Any weighing or measuring device(s) sold or installed by me for use in commerce in
Mississippi shall have been tested and issued a certificate of conformance by the National Type Evaluation Program
(NTEP) of the National Institute of Standards and Technology (NIST). (3) I shall not retain any remuneration for
repairing any weighing or measuring device unless the repairing involved causes such device to comply with the
requirements of the Mississippi Weights and Measures Law and Rules and Regulations for at least (90) days after
such repair. (4) That I will, at all times while testing, adjusting, repairing or placing in service scales, have access
to a current edition of NISST Handbook 44. (5) Violations of the provisions of the Mississippi Weights and
Measures Law and Rules and Regulations may result in the suspension or revocation of my license or other legal
remedies at law. (6) Should my license be suspended, revoked or otherwise canceled, I will surrender same to the
Mississippi Department of Agriculture and Commerce immediately. (7) A copy of the certification certificate
issued by a certified metrology laboratory on all weights used by me is attached and made a part of this application;
and (8) If license is granted, I shall employ the highest ethical standards in all information supplied and work
performed by me under the authority of such license.
_____________________________
Signature
_____________________________
Date
NOTE:
A CHECK OR MONEY ORDER FOR $50.00 MADE PAYABLE TO THE
MISSISSIPPI DEPARTMENT OF ARICULTURE COVERING PAYMENT
OF THE REQUIRED LICENSE FEE MUST BE ENCLOSED.
Enclose with this application:
License Fee of $50.00
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