PLACED IN SERVICE REPORT rev 092216. Service Person / agency form tor palcing divices into service 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'PHYSICAL LOCATION OF THE DEVICE' section. Ensure you provide the business name, phone number, address, county, city, state, and zip code clearly.
3. In the 'DEVICE' section, select the type of device from the provided codes on the back of the form. Record the date of service accurately.
4. Complete the 'MANUFACTURER', 'DEVICE DESCRIPTION', 'MODEL NUMBER', and 'RATED CAPACITY/FLOW RATE' fields. Make sure to include the NTEP Certificate of Conformance Number in the designated column.
5. Indicate whether this is a return to service, new installation, or other devices restored by checking the appropriate boxes and providing any necessary comments.
6. Fill out your agency information including name, MI registration number, contact name, address, and phone number. Confirm if it’s a new establishment by selecting yes or no.
7. Finally, sign and print your name as a certification that all information is accurate and complies with applicable requirements.

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