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Landlord Registration Form

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Address of Dwelling
Block
Lot
Check one:
1. Corporation
2. Individual
3. Business
Total Number of Dwelling Units
A. Name of Owner(s) of Record
Address
City
State
Zip Code
Phone
Email
B. If Corporation, Name, Address and Phone of Registered Agent
Name of Corporate Officers
C. Name of Managing Agent (if Applicable)
Address
City
State
Zip Code
Phone
D. Individual to Be Called in the Event of Emergency
Name
Cell Phone
Email
Address
City
State
Zip Code
E. Name of Mortgage Holder(s)
Address
City
State
Zip Code
Phone
F. Fuel Oil / Gas
Supplier Name
Grade of Fuel Used
Supplier Address
City
State
Zip Code
Signature
Date
Date
Please note: An amended registration form must be filed within 7 days after any change in the foregoing information.