Type Full Name :
Sign With Hand
City, State, ZIP
City, State, ZIP
Email
I certify that the information contained in this statement are true and accurate and that I am authorized to submit and sign the Annual Registration Statement on behalf of the owner(s) of the property and premises.

I further certify that I understand that pursuant Ordinance #2009-18 of the {[CNAME]}, that I am required to file an amended Annual Registration Statement with the {[CNAME]} within seven (7) days of any changes to the information contained herein.

Furthermore, I certify that I understand that in accordance to Ordinance 284-12 Certificate transferability, a certificate of inspection shall be transferable to a new owner, provided that the new owner has complied with the registration requirements of § 284-5, the prior owner has complied with all requirements of this chapter, and there are no outstanding violation notices.

I also certify that I understand Ordinance 284-5 Transfer of ownership where Every new owner of a rental dwelling unit, whether as fee owner or contract purchaser, shall furnish the Clerk, prior to taking possession, with any changes in the registration information occasioned by the change in ownership. Provided the prior owner has complied with all the requirements of this chapter and there are no outstanding violation notices, no new registration fee shall be required until the next annual registration is required.

By signing below, I hereby declare and certify under penalty of law that the information provided in this Annual Rental Registration Statement is true and correct in all of its particulars as of the date indicated.

{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[APHONE]}
{[AWEBSITE]}
Is this a New or Renewal application?
Mailing Address
Number of units being rented
Provide the maximum occupancy for every unit being rented
Phone #
Annual registration fee shall be set at $50 per unit. A late fee of $250 per unit, starting February 1 of the registering year, will be charged in addition to the annual registration fee, upon late registration. A late fee of $100 per unit, starting March 1 of the registering year, will be charged on the first of every month thereafter, in addition to the annual registration fee and the $250 per unit late fee, upon late registration.
Address
Owner of Record
Property Type
Fuel Oil Company
Full Address, City, State, ZIP
Address 2
Unit Information
Complete Name
Phone #
Enter the address of the rental property and select from the populated dropdown
Does the Property Owner
provide the Fuel Oil used?
Who is making this application?
Fuel Oil Number
Address
If the answer to any of the above is Yes, provide the name, address and contact information for the Fuel Oil provider.
Is Fuel Oil used?
Amount Due
Certification
Email
Name
Block
Complete Name
{[PNAME]}
Phone #
Does the owner, applicant or emergency contact live in NJ?
Email
Applicant Signature
Address
Heating Information
Applicant Information
Provide information for someone who may be reached at any time in the event of an emergency affecting the premises, any unit or dwelling space therein, including such emergencies as the failure of any essential service or system, and who has the authority to make emergency decisions concerning the premises, any unit or dwelling space, and any immediate repair and expenditures in connection thereof.
Fee Schedule
Emergency Contact Person
Phone #
Lot