Form Ppi 11 - Application For Petroleum Equipment Repairmans License - 1997 Page 2
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2Give at least three reference, other than present employer, who are familiar with your ability as a
petroleum equipment repairman:
Name:
Address:
Name:
Address:
Name:
Address:
Give at least three additional character references, not related to you:
Name:
Address:
Name:
Address:
Name:
Address:
I hereby agree that if this application is approved and a license granted, I will not seal a gasoline pump, meter or other device nor issue a
“ Placing in Service Report” unless I find, as a result of inspection, adjustment, repair and test, that the device(s) meets all requirements of
the laws, specifications, tolerances, rules and regulations applicable to same. I fully understand that the Mississippi Department of
Agriculture and Commerce may cancel my license for good cause, after careful consideration and without recourse. Should my License be
canceled I will surrender same to the Mississippi Department of Agriculture and Commerce immediately.
(License fee of $50.00 Must Accompany This Application)
Signed:
(Do Not Write Below This Line)
------------------------------------------------------------------------------------------------------------------------------------
Check Number:
Total Amount Received
Date License Issued:
License No. Issued:
Approved by:
Division Director
Remarks:
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