Iowa Division of Labor
Boiler and Pressure Vessel Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5609/515-725-5610
Fax: 515-242-5076
Application for Boiler and Pressure Vessel - Special Inspector Commission
New Renewal
Check Number:
Date Issued:
Social security number
Home address
Home phone number
Mobile phone number
Email address
Employer name
Business phone number
National board commission
National board commission initial
issuance date
Current Iowa commission
Previous Iowa commission number
If any of the information above changes, I will notify the Division of Labor within 30 days of the change. I understand
and agree that I will need to apply for a new commission if I change jobs. I agree that should I not maintain my
National Board Commission, my Iowa Special Inspector Commission becomes null and void.
I certify that the information on this form and the attachments is true and accurate to the best of my knowledge. I
understand the Division of Labor may deny this application or revoke my commission if I knowingly make false or
fraudulent statements.
I agree by making this application to receive and accept service for any official notice or mailings from the Division of
Labor at either of my addresses listed above, pursuant to Iowa code section 17A.2.
I certify that I have read and understand the Iowa code and administrative rules found at I also
understand that I may meet with the Chief Inspector for additional information.
Signature Date
Send the completed application with following attachments to the address above:
1. Copy of the applicant’s current, valid National Board of Boiler and Pressure Vessel Inspectors work card
2. $55.00 annual fee (check or money order made out to Division of Labor Boiler Safety)
Iowa Code Chapters 252J and 272D require special inspector commissions to be maintained by social security number. If you withhold your social security
number, this application will be denied. Your social security number may be shared with other government agencies. If you are behind in payments, this or future
applications may be denied, or your special inspectors commission may be suspended or revoked.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
Application for the year ending June 30, 20
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