Forms • Michigan City, IN • CivicEngage

Application for Business Registration

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Property Number (Street Number)

Suite

Street Name*

City*

State*

Zip Code*

Use of property (be specific)*

If chemicals are required for use on the property, please list chemicals

Is the business located within a residential dwelling?*

Yes

Does any of the following apply?

	Change of Use
	Expansion

Changes in Exterior or Exterior Remodel

Business Name (DBA)*

Business Phone*

Email Address*

Business Mailing Address*

City*

State*

Zip Code*

Contact Person*

Daytime Phone*

Emergency Contact Person*

Daytime Phone*

After Hours Phone*

Business Owner’s Address*

City*

State*

ZIP*

Property Owner’s Address*

City*

State*

ZIP*

Square footage of Building*

Number of Employees*

Business Hours*

Which is applicable:*

	I am the business owner
	I am the property owner

I am the leasing agent

Driver’s License Number:*

State of Issuance:*

I HEREBY CERTIFY THAT I AM THE OWNER OR AN AUTHORIZED AGENT OF THE OWNER WITH PERMISSION TO
EXECUTE THIS DOCUMENT, I CERTIFY THAT THE INFORMATION PROVIDED HEREIN IS TRUE AND CORRECT.

Your name (printed)*

Signature*

Date*

Phone*

Fax

Email:*

* indicates required fields.

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