Forms • Hagerstown, MD • CivicEngage

Property Address being Registered*

Primary Mailing Address

Owner Name*

Address line 1*

Address Line 2

City*

State*

Zip*

Primary Phone #*

Secondary Phone #

Fax #

Email*

Resident Agent Information

(if corporation or LLC)

Resident Agent Name

Address Line 1

Address Line 2

City

State

Zip

Primary Phone #

Secondary Phone #

Fax #

Email

Emergency Contact

(if different from owner)

Name

Primary Phone #

Secondary Phone #

Fax #

Email

Vacant Property Type*

	Residential - $100 (vacant residential structure)
	Residential - $500 (vacant blighted residential structure)

	Non-Residential - $250 (vacant non-residential structure)
	Non-Residential - $500 (vacant blighted non-residential structure)

Convenience Fee

$2.00

Total Due*

Payment

Name as it appears on Credit Card*

Credit Card Number*

Expiration Date of Credit Card (MM/YY)*

Type of Credit Card*

	Visa
	Mastercard

Discover

Customer Validation Number (3-digit-number on the back of the card)*

Billing Address*

Same as Owner Information

See box below for other address

Billing Address for the credit card

By checking this box I hereby affirm under penalty of perjury that the information on this application, both for a rental facility license and with regard to lead poisoning prevention, is true to the best of my knowledge and belief. I also understand if there are any changes in property ownership, owner address or agent/contact information I will notify the Code Administration Office within 10 days of the change.*

Applicant Name*

* indicates required fields.

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