Serviceman Registration Application for Installation and Service of Weighing and Measuring Devices

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Applicant Information

Prefix

Last Name*

First Name*

Middle Initial

Suffix

Company Employed By*

Address 1*

Address 2

City*

State *

Zip Code*

Ext. -

Primary Phone*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address*

Confirm E-mail Address

Registration areas selection

Validate Registration Area

Retail fuel dispensers (gpm < 20 gal)

Non-Petroleum mass flow meters

Retail fuel dispensers high flow (gpm > 20 gal)

Class I and II scales

Bulk delivery fuel meters (gpm >= 50 gal)

Retail computing scales

Taxi meters

Small capacity scales <= 300 lb

LPG meters

Medium capacity scales <= 3,000 lb

NH3 meters

All capacity scales

LNG/CNG meters

Railroad track scales

Petroleum mass flow meters

Grain moisture meters

Reference materials

Reference materials - Result fuel dispensers Bulk

NIST Handbook 44 - 2012 Edition

http://www.nfpa.org/catalog/product.asp?link_type=buy_box&pid=3096&icid=A647

http://www.nfpa.org/catalog/product.asp?link_type=buy_box&pid=30A96&icid=A647

http://www.nfpa.org/catalog/product.asp?link_type=buy_box&pid=7096SB&icid=A647

Reference materials - Taxi Meters

http://www.nist.gov/pml/wmd/h44-12.cfm"

http://www.moga.mo.gov/statutes/c413.htm

Reference materials - LPG Meters

http://www.nist.gov/pml/wmd/h44-12.cfm

http://moga.mo.gov/statutes/c323.htm

Reference materials - NH3 Meters

http://www.nist.gov/pml/wmd/h44-12.cfm

http://www.moga.mo.gov/statutes/c266.htm

Reference materials - LNG/CNG Meters

http://www.nfpa.org/codes-and-standards/document-information-pages?mode=code&code=52

http://www.nist.gov/pml/wmd/h44-12.cfm

http://www.moga.mo.gov/statutes/c323.htm

Validate Volume Reference materials - Petroleum mass flow meters

http://www.nist.gov/pml/wmd/h44-12.cfm

http://www.moga.mo.gov/statutes/c413.htm

http://www.moga.mo.gov/statutes/c414.htm

http://www.nfpa.org/catalog/product.asp?link_type=buy_box&pid=3096&icid=A647

http://www.nfpa.org/catalog/product.asp?link_type=buy_box&pid=30A96&icid=A647

http://www.nfpa.org/catalog/product.asp?link_type=buy_box&pid=7096SB&icid=A647

Reference materials - Non-Petroleum mass flow meters

http://www.nist.gov/pml/wmd/h44-12.cfm

http://www.moga.mo.gov/statutes/c413.htm

http://www.moga.mo.gov/statutes/c266.htm

Reference materials - Scales

http://www.nist.gov/pml/wmd/h44-12.cfm

http://www.moga.mo.gov/statutes/c413.htm

Reference materials - Grain Moisture Meters

http://www.nist.gov/pml/wmd/h44-12.cfm

http://www.moga.mo.gov/statutes/c413.htm

Summary of Training Experience*

Summary of Service to be Performed*

Company Security Seal Type*

Company Security Seal ID*

Registration in Other States?*

Upload Current Proof of Registration

hdn upload

Upload Name
JPEG , JPG , PDF

Professional Reference -Reference 1

Last Name*

First Name*

Middle Initial

Address*

City*

State *

Zip Code*

Ext. -

Phone*

Phone Type Ext.

E-mail Address*

Professional Reference -Reference 2

Last Name*

First Name*

Middle Initial

Address*

City*

State *

Zip Code*

Ext. -

Phone*

Phone Type Ext.

E-mail Address*

Professional Reference -Reference 3

Last Name*

First Name*

Middle Initial

Address*

City*

State *

Zip Code*

Ext. -

Phone*

Phone Type Ext.

E-mail Address*

Contact Information

Device and Commodity Program (573) 751-5639

Petroleum Program (573) 751-4278

Metrology/Moisture Meter Program: (573) 751-3105

Fax: (753) 751-0281

Please upload proof of current equipment calibration and/or certification in compliance with RSMO chapter 413 & 414

Upload Name
JPEG , JPG , PDF

Signature

I certify this information is correct

Legal Name*

Date 12/16/2018