Form Center

2. NJ Department of Community Affairs N.J.S.A. 46:8-28
4. Address of Dwelling
5. Block
6. Lot
8. Check one:

   1. Corporation
   2. Individual
   3. Business
9. Total Number of Dwelling Units
11. A. Name of Owner(s) of Record
13. Address
15. City
16. State
17. Zip Code
19. Phone
20. Email
22. B. If Corporation, Name, Address and Phone of Registered Agent
24. Name of Corporate Officers
26. C. Name of Managing Agent (if Applicable)
28. Address
30. City
31. State
32. Zip Code
34. Phone
36. D. Individual to Be Called in the Event of Emergency
38. Name
40. Cell Phone
41. Email
43. Address
45. City
46. State
47. Zip Code
49. E. Name of Mortgage Holder(s)
51. Address
53. City
54. State
55. Zip Code
57. Phone
59. F. Fuel Oil / Gas
61. Supplier Name
62. Grade of Fuel Used
64. Supplier Address
66. City
67. State
68. Zip Code
70. Signature
71. Date
    Date
73. Please note: An amended registration form must be filed within 7 days after any change in the foregoing information.
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75. 1. Receive an email copy of this form.
76. Email address

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77. Submit Submit and Print

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