Section 1 of 1 in this document

Special Inspector Commission Application

Applicant Information

This application is:

New

Renewal

Applicant's First Name

Applicant's Last Name

Applicant's Address 1

Applicant's Address 2

City

State

Zip Code

Applicant's Email

Applicant's Phone Number

QEI/QEITF Number

QEI/QEITF Expiration Date

Applicant’s Employer Information

My Employer

Employer's Address 1

Employer's Address 2

City

State

Zip Code

Manager's First Name

Manager's Last Name

Manager's Title

Manager's Email

Manager's Phone Number

Attachments

The following attachments are required:

Copy of the front of the applicant’s current valid QEI card.
Current copy of your Certificate of Liability from your employer's insurance company with your name listed in the Description of Operations

Also, a passport size photo 2x2 – (JPEG format only) needs to be submitted via email every three years - or by request - to elevators@dia.iowa.gov.

Note: When attaching documentation, you must attach all items at the same time. If you forget a document, you will need to X out and attach the documents again.

Upload File(s)

When you are finished submitting your application, a copy will be sent to your email. Print the completed application and mail it with your check or money order for $60 to: DIAL – Elevator Safety, 6200 Park Avenue, Ste. 100, Des Moines, IA 50321.