PC425 (Form AQI-1) | 1116
APPLICATION FOR APPOINTMENT AS A QUALIFIED INSPECTOR
Form AQI-1
Under Insurance Code §§ 2210.251 - 2210.2581 and 28 Texas Administrative Code § 5.4609, the
following information
is required:
PART I
PERSONAL DATA
Name:
Last
First
MI
Title or Position:
Employer:
Business Mailing
Address:
St./P.O. Box
City
County
State
Zip Code
Home Mailing
Address:
St./P.O. Box
City
County
State
Zip Code
Email Address:
Which address would you like TDI to use for correspondence?
BUSINESS
HOME
(check one)
Business Phone:
Home Phone:
PART II
EDUCATION AND EXPERIENCE
Section A: Current Texas
Licensed Professional Engineer Information
Texas Registration Number
Field of Expertise
No. of years
Months
Section B: College
Education
College or University
City, State
Course/Major
Degree Earned
Section C: TDI Orientation
Date attended TDI Orientation Webinar
Texas Department of Insurance | www.tdi.texas.gov
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PC425 (Form AQI-1) | 1116
Section D: Other
Education or Training
Course
Subject Matter
Dates Attended
Section E: Experience in the
design of structures to meet windstorm resistant building requirements.
1. Have you designed structures and calculated wind loads for structures located in high wind
areas?
Yes
No
2. What percentage of your work has been for the design of structures in high wind
areas?
Percent
3. How long have you been designing structures in high wind areas?
Number of years
months
Section F:
Signature (in ink)
Date
Under Insurance Code §
2210.256,
if the commissioner finds that an appointed qualified inspector knowingly, willfully, fraudulently, or with
gross negligence signed or caused to be prepared an inspection report that contains a false or fraudulent
statement, the commissioner may, after notice and hearing, issue an order directing the appointee to pay a fine
not to exceed $5,000. Under Insurance Code art. 21.47, a person commits a felony offense if the person knowingly
or intentionally makes, files or uses any instrument in writing required to be made to or filed with the
commissioner, either by the Insurance Code or by rule, when the instrument in writing contains any false,
fictitious, or fraudulent statement or entry with regard to any material fact.
Return application to:
Texas Department of Insurance
Engineering Services Program
Mail Code 104-ENG
P.O. Box 12030
Austin, Texas 78711-2030
Questions? Contact us at 800-248-6032, option 5, or at Engineering@tdi.texas.gov.
Access and Correction of Personal Information
With few exceptions, you are entitled to be informed about the
information that TDI collects about you.
Under Government Code § 552.021 and § 552.023, you have a right to review or receive copies of
information about yourself, including private information.
However, TDI may withhold information for reasons other than to protect your right to privacy. Government Code
§ 559.004 entitles you to request that TDI correct
information that TDI has about you that is incorrect. For more information about the procedure and costs for
obtaining information from TDI please visit
www.tdi.texas.gov/open-records.html. For information about the procedure for correcting information kept by
TDI, please visit www.tdi.texas.gov/commissioner/legal/lccorprc.html.
You may also send a request for information to OpenRecords@tdi.texas.gov.
Texas Department of Insurance | www.tdi.texas.gov
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