Applications for certification shall be on a form prescribed by the department and shall include the following:
I. The full name and address of the person applying for the certification.
II. The name and address of a person whose domicile is in the state, and who is authorized to receive and accept service of summons and legal notices of all kinds for the applicant.
III. The type of apparatus used to apply salt or salt alternative whether liquid or dry.
IV. Any other information deemed necessary by the department.