asbestoscompanynamechangelicenseapplication.docVIP

www.dshs.state.tx.us/asbestos In Texas Only: 800 572-5548 Local 512 834-6600 Fax: 512-834-6614 FOR DSHS USE ONLY BUDGET/FUND: ZZ112-178 Remit #: Remit Date: Asbestos Company Name Change License Application DO NOT WRITE IN THIS BOX – FOR DEPARTMENT USE ONLY Rcvd Date: Init. Post Mark Date: Rvw Date: Init Aprv Date: Init. Amt Rcvd:$ FY: Expiration Date: Init Print Date: Init Mail Date: Init INSTRUCTIONS: Submit completed application with a $20 fee and legal documentation of name change to the address provided below. Enter your current license/registration number: Expiration Date: Old Name: Tax Payers Identification number License # NEW NAME: send in legal documentation of name change. SOLE OWNER/PROPRIETORSHIP LLP Limited Liability Partnership LLC Limited Liability Company LP Limited Partnership PARTNERSHIP CORPORATION DBA Doing Business As Legal Business Name: Telephone Number include area code Dba name if applicable Tax Payers Identification number License Mailing Address include suite # City State Zip Code Business Physical Address include suite # City State Zip Code Responsible Persons Name License # if applicable Telephone Number include area code CERTIFICATION: I certify that I am authorized by the Applicant/company to make this application and to sign on its behalf. I have read and understand the applicable rules and agree on behalf of the applicant to comply with them. I understand that it is a violation of DSHS rules and the Texas Penal Code §37.10 to submit any false or fraudulent information or documents in order to obtain a license. All information I have provided on this application is true, correct, and complete to the best of my knowledge. Signature of Responsible Person or Owner Date Mailing address for applications containing money: Regulatory Licensing Unit MC 2003 Department of State Health Services PO Box 149347 Austin, Texas 78714-9347 Mailing address for all other mail