Once completed, this form must be printed, signed and then submitted to the appropriate City of Lewisville department along with any required fees.

Backflow Registration/Application
City of Lewisville
P.O. Box 299002, 151 W. Church Street, Lewisville, Texas 75057
Tel: (972) 219-3480 Fax: (972) 219-3772


Registration Requirements

	1.	State Backflow Prevention Assembly Tester license
	2.	State Fire Sprinkler Certificate of Registration (if testing fire DCVA's)
	3.	Drivers License
	4.	Current calibration test report
	5.	Test gauge must be brought in to verify model/serial number
	6.	$50.00 registration fee - cash or check only

Applicant's Name:
Company Name:
Company Address:

City:

State:

Zip:

Work #:

Cell/Home #:


Type of DCVA's You Will Be Testing: (check all applicable boxes)
Domestic	Irrigation	Fire
Testing Equp. Serial #		Model:

IMPORTANT NOTE TO APPLICANT

In the event that any part of the registration expires, i.e. calibration test report, state license/s, the registration will automatically become void. If registration requirements are brought back into compliance within the paid registration period, re-installment will occur. Registrations are valid from March 1st, to March 1st, of each year (registrations are not pro-rated) Partial applications will not be accepted. We do not charge for test forms. The quantity of forms issued will be for current devices to be tested only. Tester must return completed, white form copy to the City. Applications may be mailed to the address above.