Form Com 5169 - Irrevocable Consent To Legal Service - Department Of Commerce printable pdf download

Form Com 5169 - Irrevocable Consent To Legal Service - Department Of Commerce

Department of Commerce

Print Form

Division of State Fire Marshal

Bureau of Testing and Registration

8895 East Main Street - P.O. Box 529

Reynoldsburg, Ohio 43068

(6140 752-7126 Fax (614) 995-4206 TTY/TDD 800-750-0750

IRREVOCABLE CONSENT TO LEGAL SERVICE

, whose residence is at

(Name)

(Street Address)

(City)

(State)

after full disclosure of the intended use hereof do hereby consent irrevocably to service of process from

any and all courts, administrative agencies and administrative boards having competent subject matter

jurisdiction over any and all activities which I may undertake as a (please select applicable box)

certified installer of fire protection

installer/inspector of underground storage tank

equipment in Ohio. I also hereby irrevocably waive any and all rights I may otherwise have to challenge

the jurisdiction over my person of all such courts, administrative agencies and administrative boards.

Applicant Signature

Date

Witness

State Of ______________ County of ______________________

Before me appeared the above named person who after producing proper identification, acknowledges

that they signed the foregoing instrument and that their signing was their free act. In testimony

whereof, I have hereto subscribed my name and affixed by seal this ______ day of ____________,

20 __ at ___________________________. County of ____________, and State of ____________.

Signature of Notary

Official Title

THIS FORM MUST BE NOTORIZED TO BE VALID.

An Equal Opportunity Employer and Service Provider

COM 5169 REV 1/11

Form Com 5169 - Irrevocable Consent To Legal Service - Department Of Commerce