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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 Other (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 Other (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 Other (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 Other (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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