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Device and Scanner Registration Form

2. Business Name*
3. Date*
   Date
5. Corporate Name (If Applicable)
7. Business Address*
8. City*
9. State & Zip Code*
11. Billing Address

    1. Check If Same As Business Address
13. Billing Address
14. City
15. State & Zip Code
19. Contact Name*
20. Contact Title
21. Contact Email*
23. Contact Phone Number*
24. Extension
28. How Many Different Device Types Are Being Registered?*

    1. 1
    2. 2

    1. 3
    2. 4
30. Devices*
    -- Select One --Computing scaleComputing scale with POS systemScanners/Point of Sale SystemCounter scaleHanging scalePortable Platform scaleJeweler/Prescription/Cannabis scaleHopper scaleRailway scaleDormant scaleLivestock/Animal scaleVehicle scaleTaxi meterVapor submeterWater submeterVehicle meterElectric meterFabric/Cordage/Wire meterLPG meterRetail Motor Fuel Device EVSEOther (please specify below)*
31. Device Capacity (if applicable)
32. Quantity of Device(s)
34. Devices
    -- Select One --Computing scaleComputing scale with POS systemScanners/Point of Sale SystemCounter scaleHanging scalePortable Platform scaleJeweler/Prescription/Cannabis scaleHopper scaleRailway scaleDormant scaleLivestock/Animal scaleVehicle scaleTaxi meterVapor submeterWater submeterVehicle meterElectric meterFabric/Cordage/Wire meterLPG meterRetail Motor Fuel Device EVSEOther (please specify below)*
35. Device Capacity (if applicable)
36. Quantity of Device(s)
38. Devices
    -- Select One --Computing scaleComputing scale with POS systemScanners/Point of Sale SystemCounter scaleHanging scalePortable Platform scaleJeweler/Prescription/Cannabis scaleHopper scaleRailway scaleDormant scaleLivestock/Animal scaleVehicle scaleTaxi meterVapor submeterWater submeterVehicle meterElectric meterFabric/Cordage/Wire meterLPG meterRetail Motor Fuel Device EVSEOther (please specify below)*
39. Device Capacity (if applicable)
40. Quantity of Device(s)
42. Devices
    -- Select One --Computing scaleComputing scale with POS systemScanners/Point of Sale SystemCounter scaleHanging scalePortable Platform scaleJeweler/Prescription/Cannabis scaleHopper scaleRailway scaleDormant scaleLivestock/Animal scaleVehicle scaleTaxi meterVapor submeterWater submeterVehicle meterElectric meterFabric/Cordage/Wire meterLPG meterRetail Motor Fuel Device EVSEOther (please specify below)*
43. Device Capacity (if applicable)
44. Quantity of Device(s)
46. *Retail Motor Fuel Devices are counted by each grade of gasoline and/or diesel on each dispenser.
50. * Notes
    Please include any other information, concerns, or questions here.
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

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