Fillable TEXAS ELEVATOR INSPECTOR Pursuant to Chapter 754, Health (Texas Real Estate Contracts)

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TEXAS ELEVATOR INSPECTOR Pursuant to Chapter 754, Health (Texas Real Estate Contracts)

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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TEXAS ELEVATOR INSPECTOR
Pursuant to Chapter 754, Health and Safety Code
NOTE: ALL INFORMATION MUST BE TYPED OR PRINTED IN INK.
IF ALL REQUIREMENTS FOR REGISTRATION ARE NOT MET WITHIN TWELVE (12) MONTHS OF THE FILING
DATE, THIS APPLICATION WILL BE CLOSED.
1. Applicant’s Full Name:
Last, First, Middle Name, Suffix (Jr., Sr., III)
2. Social Security Number: 3. Date of Birth: 4. Gender:
Male Female
Month/Day/Year
5. Business Name(s): (Use additional pages if necessary) Phone Number:
Attach proof of registration of name (Area Code) Phone Number
6. Business Location: STREET ADDRESS MUST BE DESIGNATED BELOW. (A license will not be issued to a P.O. BOX ONLY)
Number, Street, Suite Number/Apartment Number City State Zip Code
7. Mailing Address: (P.O. Box is allowed for this address)
Number, Street, Suite Number/Apartment Number or P.O. Box City State Zip Code
Contact Information
Phone Number: Fax Number: Email Address:
(Area Code) Phone Number (Area Code) Phone Number (ex: johndoe@gmail.com)
8. (a) Have you ever been convicted of, or placed on deferred adjudication for, any misdemeanor
or felony, other than a minor traffic violation?
Yes No
(b) Have you had a license, certification or registration suspended, revoked or denied in any
state?
Yes No
If the answer to (a) or (b) is YES, submit copies of all indictments, information, judgements, orders, and charges as
well as a detailed written explanation of the relevant events.
9. Certification Number: Issue Date: Expiration Date:
STATEMENT OF APPLICANT
I CERTIFY THAT I HAVE READ AND WILL ABIDE BY THE ELEVATOR ACT AND THE TEXAS DEPARTMENT OF
LICENSING AND REGULATION RULES, TITLE 16, TEXAS ADMINISTRATIVE CODE, CHAPTER 74 (THE RULES).
UPON REQUEST OF THE DEPARTMENT, I AGREE TO MAKE AVAILABLE ALL RECORDS REQUIRED BY THE
ACT.
By signing this application, I certify all information submitted on this and attached forms is true and accurate.
Date Signed Signature of Applicant
TDLR Form ELE004 rev August 2021
Page 2 of 2
click to sign
signature
click to edit
Important Notice Regarding Your Application
1. If you submit an insufficient fee amount with this application, or submit an outdated application form, it may
be returned to you. To verify the correct form version and required fees, consult the TDLR website or contact TDLR
using the information below.
2. The fee for registration as an Elevator Inspector is $50.00. Submit one check or money order in the amount of $50.00
payable to TDLR with this application.
3. ALL data requested on this application form must be completed.
4. This application must be signed and dated by the applicant.
5. A copy of both sides of the applicant’s ANSI Certification Card must be submitted with this application.
6. If you wish to order Test Tag Kits, please return the Elevator Test Tag Purchase Form with the appropriate fee.
SEND YOUR COMPLETED APPLICATION AND REQUIRED DOCUMENTS TO:
Texas Department of Licensing and Regulation
P.O. Box 12157
Austin, TX 78711-2157
Documents submitted with your application will not be returned. Keep a copy of your completed application, all
attachments, and your check or money order. Do not send cash.
For additional information and questions, please visit the TDLR website. You can request assistance or submit required
attachments via TDLR webform or fax (512) 463-9468. You may contact Customer Service Representatives by calling
(800) 803-9202 (in state only), or (512) 463-6599, Relay Texas - TDD: (800) 735-2989. Customer Service Representatives
are available Monday through Friday from 7:00 a.m. until 6:00 p.m. Central Time (excluding holidays).
TDLR Public Information Act Policy:
This document is subject to the Texas Public Information Act. With certain exceptions, information in this document may
be made available to the public. For more information, view the TDLR Public Information Act Policy.
TDLR Form ELE004 rev August 2021
Page 2 of 2
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TEXAS ELEVATOR INSPECTOR Pursuant to Chapter 754, Health (Texas Real Estate Contracts)

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Completed 26 April 2022

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