Application for Elevator Special Inspector Commission

Instructions

Please send payment to the following address:

Iowa Department of Inspections, Appeals, & Licensing
Elevator Safety
6200 Park Ave. Suite 100
Des Moines, IA 50321-1371

The following documents are needed to complete your application.

  1. Copy of the applicant’s current, valid QEI certification (attach online, or mail).
  2. $60.00 annual fee (check or money order made out to Department of Inspecitons, Appeals & Licensing – Elevator Safety)
  3. Proof of insurance. The applicant shall provide evidence of insurance covering liability for death or injury caused by acts or omissions by applicant. The minimum required insurance coverages are (employer may hold the policy), this can be submitted online or via mail:
    1. $1,000,000 for bodily injury or death of one person in an accident
    2. $5,000,000 for bodily injury or death of more than one person in an accident
    3. $100,000 for property damage in one accident.

Applicant Name

Name

Home Address

Address

Contact Information

Employer Information

Employer Address

NAESA QEI Information

EIWPF QEI Information

Other QEI Certifying Agency Information

Certification Certificate

Please attach a copy of your Certification.  This is required as part of your application.

One file only.
50 MB limit.
Allowed types: gif, jpg, jpeg, png, odf, pdf, doc, docx, zip.

Proof of Insurance

One file only.
50 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, svg, zip.

Background Information

High School Information

Work Experience

Please list the last three years of full time work experience in the construction, installation, repair or inspection of devices regulated by the Iowa State Elevator Code.
Re-order Employer Name Employer Address Employer Phone Description of Work Date of Employment Start Date of Employment End Weight Operations
Or Current Date if Still Employed
more items

Attestation

I certify that all of the information provided on this form and attachments are true and accurate to the best of my knowledge. 

If any of the information above changes, I will notify the Department of Inspections, Appeals, & Licensing within 30 days of the change. 

I understand and agree that I will need to apply for a new commission if I change jobs. 

I agree that should I not maintain my QEI certification, my Iowa Special Inspector Commission becomes null and void. 

I understand the Department of Inspections, Appeals, & Licensing may deny this application or revoke my commission if I knowingly make false or fraudulent statements. 

I agree by making this application to receive and accept service for any official notice or mailings from the Division of Labor at either of my addresses listed above, pursuant to Iowa code section 17A.2. 

I certify that I have read and understand the Iowa code and administrative rules found at www.iowaelevators.gov

I also understand that I may meet with the Chief Inspector for additional information.

Signature

Signature Required

Payment Information

Please send your $60.00 annual fee to the following address:

Iowa Department of Inspections, Appeals, & Licensing
Elevator Safety
6200 Park Ave. Suite 100
Des Moines, IA 50321-1371