Free VARIANCE APPLICATION - Indiana

PARTNERSHIP OR LIMITED PARTNERSHIP ELEVATOR CONTRACTOR LICENSE RENEWAL APPLICATION
State Form 52476 (12-05) Approved by State Board of Accounts, 2006

Division of Fire & Building Safety Division of Elevators 402 West Washington Street, W246 Indianapolis, IN 46204 http://www.in.gov/dhs/fire fax: (317)232-6609 (317)232-0146

ATTACH ADDITIONAL PAGES AS NEEDED TO COMPLETE THIS APPLICATION 1. APPLICANT INFORMATION Name of Partnership or Limited Partnership: Address: City: Contact name: Telephone Number: 2. TYPE OF ENTITY The applicant is one of the following (check applicable box): Partnership Limited Partnership 3. PROOF OF ELIGIBILITY Include the name, business address, phone number, and electronic mail address of every partner (for a partnership) or every general partner (for a limited partnership) who holds a valid elevator contractor license issued by Indiana. 4. PROOF OF INSURANCE A Certificate of Insurance that complies with the requirements of IC 22-15-5-14. 5. PROOF OF WORKMAN'S COMPENSATION COVERAGE Proof demonstrating that you are covered by worker's compensation under IC 22-3-2-5 must be submitted with the application. 6. APPLICATION FEE The application must include payment of the license fee of $500. If paying by check or money order, make it payable to the Fire and Building Services Fund. If paying by Visa or MasterCard, complete the Credit Card Payment form: A check or money order for $500 is enclosed. Payment will be made by Visa or MasterCard and the Credit Card Payment form has been completed and is enclosed. 7. AFFIRMATION I hereby affirm under penalty of perjury that all of the information provided with this application is true to the best of my knowledge: Signature: _________________________________________ Date: _________________________________________ State: Title: E-mail: ZIP Code: C#:

PARTNERSHIP OR LIMITED PARTNERSHIP ELEVATOR CONTRACTOR LICENSE RENEWAL APPLICATION CREDIT CARD PAYMENT The application must include payment of the license fee of $500. If paying by Visa or MasterCard, complete the following information:
Full Name on Credit Card: _____________________________________________________________ Billing Address Street:____________________________________________________________________________ City:___________________________________ State _____________ ZIP Code _______________ Phone Number:___________________________________ Credit Card (check one): Visa MasterCard

Account Number: _____________________________________________ Expiration Date (month/year): ______ / _______ CVV2 Number (last 3 digits of the number in the signature block on the back of the card): _________ By signing, Cardmember agrees to the obligations set forth by the Cardmember's Agreement with the issuer. ______________________________________________ Signature