Form Sf228 - Licensed Employee Termination Notice printable pdf download

Form Sf228 - Licensed Employee Termination Notice

SF228 | 0215

Licensed Employee Termination Notice

For All Types of

Fire Alarm, Fire Extinguisher & Fire Sprinkler

Licenses or Permits

This form should be completed and returned to the address below for any licensee who is to be terminated under a

registered firm that is shown on his or her license.

LICENSEE INFORMATION

Name _______________________________________________________________________________________

(Last)

(First)

(Middle)

License number ____________________________

Effective DATE of termination

TO BE COMPLETED BY THE EMPLOYER

I certify that this individual will not be an employee or agent of this firm on the effective date shown above.

Name of registered firm ______________________________________

Web site Addr: _________________

C of R. No.

E‐Mail Addr: __________________________

Signature of authorized representative of firm:

Signature ______________________________________________

Date ____________________________

Printed name ___________________________________________

Title _____________________________

Mailing Address:

State Fire Marshal’s Office

Physical Address:

State Fire Marshal’s Office

Mail Code 112‐FM

333 Guadalupe Street

P. O. Box 149221

Austin, TX 78701

Austin, Texas 78714‐9221

Fax No.

(512) 490‐1056

Web site address:

NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under

sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including

private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the

Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information

about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the

Agency Counsel Section of TDI’s General Counsel Division at (512) 676‐6551 or visit the Corrections Procedure section of TDI’s website at

Texas Department of Insurance |

1/1

Form Sf228 - Licensed Employee Termination Notice

Related Articles

Related forms

Related Categories