Type Full Name :
Sign With Hand
Registration Fee
Address *
Does the Owner have a local agent? If "Yes" please fill out the section below.
City, State, ZIP *
Owner Information
If the Owner is NOT a resident of Your Town, a local agent MUST be designated as a contact person
Water
If Fuel Oil is used at this property then provide details of the fuel oil provider
Block
Phone *
Utility Information
Oil
Electric
Amount Due
Is Fuel Oil Used at this Property? *
Complete Name *
Phone *
123 Main Ave, Your Town, USA 90210
(555) 973-2212
www.yourtown.us
Is the Emergency Contact person the same as Owner above? If "No" please fill out the section below.
Number of Units Leased *
Fuel Oil Information
Complete Name *
Applicant Signature *
City, State, ZIP *
Address *
Emergency Contact Information
Address *
Address *
Your
Town
Gas
Phone *
City, State, ZIP *
Lot
Property Type *
Email *
Provide details for an emergency contact person for the property. The emergency contact person must be local and authorized to act or perform work in the event of an emergency.
City, State, ZIP *
Agent Information
Complete Name *
Address *
Complete Name *
Number of Units Owned *
There is a fixed fee of $25.00 for the Landlord Registration.
Landlord Registration
Property Information
Specify which of the following utilities are provided at this property by the Owner (select all that apply)