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STATE

OF NEW DEPARTMENT OFFICE OF STATE 10 HAZEN CONCORD,

APPLICATION

HAMPSHIRE OF SAFETY FIRE MARSHAL DRIVE NH 03305

FOR AGENTS LICENSE

TO SELL OR INSTALL LIGHTNING RODS This is to certify that the person named herein, being suitable, have been duly appointed as agent for the following licensed dealer: . 1

2.

Name of individual to be an agent: Business Address: Telephone Number: Residence for past five years: Have you ever been licensed in any other state(s)?:.

.If so, list state(s):

3.

4.

5.

6.

I have read the law regulating the sale of lightning rods and understand its provisions and hereby agree to comply with RSA Chapter 323 and the State Fire Code relating to the sale and installation of lightning rods. Signature: Print Name: Subscribed and sworn to before me this day of.

Justice of the Peace/Notary Public TO BE FILLED OUT BY DEALER: Date I hereby request that the following person be licensed as an agent to sell or install lightning rods.

I. 2.

3. Dealer Signature Print Name:

Fee $10 each for Agents License. Make Check payable to: State ofN.H. DSFS 72

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