Backflow Test Company Application

Company/Owner Name

Business Address

Business Address 2

City/Town

State/Province

ZIP/Postal Code

Business Phone Number

Business Fax Number

Company E-Mail Address(es): (Include up to three)

Email (Receives email confirmation)

ROC License

Copies of the ROC License must be attached

AZ Registrar of Contractor’s License Number

Type

Expiration Date

Upload a copy of the ROC License

Certificate of Insurance

Copies of the Certificate of Insurance must be attached

Insurance Company Name

Agent Name

Phone Number

Policy Number

Amount

Expiration Date

Upload a copy of the Certificate of Insurance