Ck Registration Form – Fill Out and Use This PDF

	Multi-Tenant Registration Application	Account Number: ___________
		Renewal	New

IMPORTANT!!! - A CERTIFICATE OF REGISTRATION WILL NOT BE ISSUED UNTIL ALL CURRENT FEES AND FINES RESULTING FROM THE OPERATION OF THE MULTI-TENANT PROPERTY (OR PROPERTIES) ARE PAID OR SETTLED

(FOR OFFICE USE ONLY)

ACCOUNT NUMBER: ______________________________	DATE PAID: _______/______/_______
LICENSE FEE PAID: $_________________	INSTRUMENT NUMBER: ___________________________
	INSTRUMENT TYPE: [ ] CK [ ] MO [ ] CC [ ] CASH

PAYOR: _____________________________________________________________

(If different than customer/applicant, capture address, C/S/Z, phone number)

ADDRESS: ___________________________________________________________

CITY: ___________________________ STATE: _____ ZIP: __________-________ PHONE: (______) _______-__________

This application must be completed by the person who owns, operates, or controls the property, and returned with the applicable, nonrefundable fee of $10.00 per unit, whether occupied or unoccupied. Please update any information that is incorrect on this application in the spaces provided below.

*Applicant’s Name:				*Applicant’s Phone No:
*Applicant’s Address / Zip Code:
*Multi-Tenant Property or Properties owned by a(n):			___Individual ____Corporation ____Partnership ____ Other:_______________________
					(Specify)

*Property Owner(s) of Record: __________________________________________________________________________________________________

*Property Owner(s) Address: ___________________________________________________________________________________________________

*Property Owner(s) Business Phone: _________________________ Fax: ___________________ Email: ____________________________________

*If this property is owned by a corporation, provide the following information:

1.Name of Corporation’s Registered Agent: ___________________________________Phone: ____________________ Fax: ____________________

2.Registered Agent Address: __________________________________________________________________________________________________

3.Name of Corporation’s President: _________________________________________ Phone: ____________________ Fax: ____________________

4.Corporation’s President Business Address:____________________________________________________________________________________

*Required Information – Application will not be accepted if this information is not provided. Put N/A if Non Applicable

If property owned by a partnership or other business association, provide name, address and telephone number of a high managerial agent. “High Managerial Agent” means partner(s) in a partnership, officer(s) of a business association, director(s) of a business association, or any agent/employee who has the duties of such responsibility that the agent’s/employee’s conduct represents the policy of the partnership or business association.

Name(s) of High Managerial Agent(s): ___________________________________________________________________________________________

Job Title of Managerial Agent(s): _______________________________________________________________________________________________

Business Address(es) of High Managerial Agent:__________________________________________________________________________________

________________________________________________________________________ Phone: ____________________________________________

I am the person who owns, controls, or operates the Multi-Tenant property that is the subject of this application. I have read the completed application and know the same is true and correct and hereby agree that, if a certificate of registration is issued, I will comply with all applicable provisions of Chapter 27 of the Dallas City Code, as amended, and all applicable state laws. I accept responsibility for payment of all fees and fines that may result from the operation of the Multi- Tenant property.

Signature of Owner/Operator/Person in Control (Required)		Driver’s License or Identification Number – Issuing State (Required)
CCS-FRM-274	EFFECTIVE DATE 10/03/2011		REV 4