ELEVATOR TEST DATA TAG ORDER
Pursuant to Chapter 754, Health and Safety Code, Elevators, Escalators and Related Equipment
NOTE: ALL INFORMATION MUST BE TYPED OR PRINTED IN INK.
1. Inspector’s Full Name:
Last, First, Middle Name, Suffix (Jr., Sr., III)
2. Texas Elevator Inspector Number:
3. Certification Number:
Issue Date:
Expiration Date:
4. Address Where Tags Are to be Mailed:
5. Phone Number:
Number, Street, Suite Number/Apartment Number City State Zip Code
(Area Code) Phone Number
Order Tag Sets Below
Event
Code
Item Description
Number
of
Sets
Amount
02090
Test Tags
(sold ONLY in sets of 100)
Multiply by $200.00 per set and enter amount
TDLR Form ELE015 rev August 2021
PAY THIS EXACT AMOUNT
$ 0.00