Amusement Ride Certificate of Inspection

500 Clinton Center Drive, Clinton, MS 39056 Telephone: 601-923-7700

Website: www.dor.ms.gov Email: amusementdecals@dor.ms.gov

Fax: 601-923-7188

There is a limit of twenty-five (25) rides per Application for Permit to Operate Amusement Ride and Attraction Safety. A new application and fee will be required for additional rides.

Name under which business operates_______________________________________________________ FEIN/SSN___________________________

Owner’s Name:_________________________ Office Telephone:_____________________ Cell:___________________ Fax:_________________

Processing will NOT complete until all information is present PLEASE PRINT CLEARLY

Ride Name Manufacturer Name & Year Built

Serial Number Name & Telephone of Operator Decal Number (Department

Use Only)

Amusement Ride Certificate of Inspection Inspector: I hereby certify and affirm that on the date shown below I personally performed the mechanical safety inspection of the amusement ride(s) or structure(s) named above and found that the ride(s) or structure(s) meet the standards for coverage as required by ASTM International Standard F770-19. Inspection Date Phone Number Print Inspector’s Name Inspector’s Signature