ARIZONA DEPARTMENT OF AGRICULTURE
WEIGHTS AND MEASURES SERVICES DIVISION
1688 W. Adams Street, Phoenix, AZ 85007 hps://agriculture.az.gov
Phone: 602‐542‐3578 Fax: 602‐542‐0466
E‐mail: licensing@azda.gov State Ombudsman: 602‐277‐7292
REGISTERED SERVICE REPRESENTATIVE (RSR)
APPLICATION
LICENSE FEE = $4.80
(Invoice will be sent to RSA aer applicant passes exam)
APPLICANT: I will comply with applicable secons of A.R.S. Title 3, Chapter 19, A.A.C. Title 3, Chapter 7, and NIST Handbook 44. Falsificaon of any informaon on this form could result in
revocaon or denial of a license. I also understand that I may be subject to civil penales under A.R.S. § 3‐3475 if a violaon occurs.
APPLICANT NAME SIGNATURE DATE
RSA: I cerfy that the applicant meets all legal requirements for an RSR license, and possesses the necessary technical knowledge, reference materials, and cerfied tesng equipment to
perform required RSR dues.
RSA REPRESENTATIVE SIGNATURE DATE
DWM‐162 (rev. 02/2018)
APPLICANT NAME: EMPLOYED BY: RSA#:
Were you licensed within the past year as an RSR? Yes No If yes, indicate your RSR#: Previous employer’s RSA# (if applicable):
Has your license ever been suspended or revoked? Yes No If yes, indicate the year: Reason for revocaon:
Type of device(s) you are applying for:
(NOTE: Your RSA must be qualified to install this device type)
Small Capacity Scales Large Capacity Scales Fueling Meters
Water Meters LPG Meters Other ___________________
(NOTE: Vapor Recovery applicants must use the Vapor Recovery Registered Servce Representave (VRRSR) Applicaon Form)
Indicate Specific Experience:
Indicate Specific Technical Training and Knowledge of NIST Handbook 44:
Please submit completed form to AZDA Licensing in person at 1688 W. Adams Street, Phoenix, AZ 85007. Hours: Mon‐Fri 8:00am‐11:00am & 1:30pm‐3:30pm
