Forms • Hagerstown, MD • CivicEngage

Vacant Structure License Renewal Application

Leave This Blank:

Property Address(es) being Registered*

License #(s)*

Vacant Property Type*

	Residential - $100 (vacant more than 12 months)
	Commercial - $500 (vacant 2 years - 4 years)
	Commerical - Fee Exempt (street level occupied and upper floors are vacant)

	Commercial - $250 (vacant 6 months - 2 years)
	Commercial - $1000 (vacant over 4 years)

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*

Email*

* indicates required fields.

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