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2. BUSINESS INFORMATION
4. Name of Business*
5. Corporation/Other Name
7. Business Address*
9. City*
10. State*
11. Zip Code*
13. Business Phone Number*
14. Business Fax Number
16. Business Email Address*
17. Business Website
19. Business Mailing Address (if applicable)
21. City
22. State
23. Zip Code
27. EMERGENCY CONTACT INFORMATION (Property/Building Owner)
29. Property *

    1. Owned
    2. Leased
30. If Leased, Name of Property Owner
31. Property Owner Phone Number
33. Associated/Emergency Contact Person*
34. Phone Number*
36. Is there an alternate contact number?
    -- Select One --YesNo
37. If so, what is the alternate phone number?
41. STATE LICENSES/PERMITS REQUIRED (If applicable, must provide copy)
43. Are you required to have a State of Michigan License or Permit for this type of business?*

    1. Yes
    2. No

    if yes, please describe below

45. Type of Permit/License
46. Permit/License Number
48. Date Issued
    Date Issued
49. Date Expires
    Date Expires
53. ALARM INFORMATION
55. Name of Alarm Company
56. Phone Number
58. Does it Reset Automatically?

    1. Yes
    2. No
59. Dog on Premise?

    1. Yes
    2. No
63. AFFIDAVIT AND SIGNATURE

    (All Owners/Applicants listed must sign this Application)

65. Electronic Signature Agreement*

    I (We) and/are the OWNER/AGENT of said business making application for this Business Registration Certificate and/or am otherwise an authorized representative of said business. I(We) authorize the verification of the information provided on this application. I (We) am a citizen of the United States of America and otherwise authorized to do business under the laws of the State of Michigan and the United States of America. I (We) depose and state that all of the information provided in the foregoing application is true to the best of my knowledge, information, and belief.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
67. Name of Owner(s)/Agent(s) agreeing to the above affidavit*
69. Electronic Signature*
70. Date Signed
    Date Signed
72. Electronic Signature (if applicable)
73. Date Signed (if applicable)
    Date Signed (if applicable)
77. REQUIRED DOCUMENT(S)

    Please include the following with this application:

    Copy of State of Michigan License or Permit (if applicable)

    Copy of Driver's License

79. File Upload*
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit Submit and Print

* indicates a required field