CONVEYANCE DEVICE REGISTRATION FORM - CONVEYANCE_DEVICE

LOUISIANA DEPARTMENT OF PUBLIC SAFETY

PUBLIC SAFETY SERVICES

OFFICE OF STATE FIRE MARSHAL

CONVEYANCE DEVICE REGISTRATION FORM

NOTE: R.S. 40:1664.1, et seq. requires that beginning July 1, 2019, owners of conveyance devices installed prior to July 1, 2019 must register the devices with the Office of State Fire Marshal. This law also requires firms that install conveyance devices on or after July 1, 2019 must register the devices with the Office of State Fire Marshal within thirty (30) days of installation.

OWNER OF CONVEYANCE DEVICE

NAME OF OWNER:

OFFICE ADDRESS:

TELEPHONE:

EMAIL ADDRESS:

CITY:

STATE:

ZIP:

OWNER REPRESENTATIVE OF CONVEYANCE DEVICE

NAME OF PERSON REGISTERING THE DEVICE:

OFFICE ADDRESS:

TELEPHONE:

EMAIL ADDRESS:

CITY:

STATE:

ZIP:

Entity/Individual registering device must select one of the following:

LICENSED FIRM

LICENSED FIRM (Installing/Maintenance/Inspection)

OWNER MANAGED

^{Optional *}

LICENSED FIRM:

^{Optional *}

FIRM ADDRESS:

^{Optional *}

OSFM LIC:

^{Optional *}

EXP DATE:

^{Optional *}

TELEPHONE:

^{Optional *}

EMAIL ADDRESS:

^{Optional *}

CITY:

STATE:

^{Optional *}

ZIP:

NAME OF MECHANIC/INSPECTOR SERVICING THE DEVICE:

ADDRESS:

OSFM LIC:

EXP DATE:

TELEPHONE:

EMAIL ADDRESS:

CITY:

STATE:

ZIP:

If you have more than eight (8) devices to register you must initiate a new registration form.

ACKNOWLEDGEMENT

The information entered on this form is true to the best of my knowledge and belief. I understand that any willful falsification of pertinent information required on this form or failure to properly register the conveyance device(s) may be considered a violation of R.S. 40:1664.1, et seq. and subject to administrative penalty by the Office of State Fire Marshal.