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2. Today's Date*
   Today's Date
4. Name of Closed Business*
6. Former Address of Business*
8. City*
9. State*
10. Zip Code*
12. Last day of operation in the City of Romulus*
    Last day of operation in the City of Romulus
14. OWNER/AGENT*
16. Phone Number*
17. Job Title*
19. Electronic Signature Agreement*

    I affirm that I am authorized to speak on behalf of said company and that the information provided in this statement is true to the best of my knowledge and belief.

    By checking the "I agree" box below, you agree and acknowledge that 1) the statement is factual, 2) your application will not be signed in the sense of a traditional paper document, 3) 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 4) you may still be required to provide a traditional signature at a later date, if necessary.

    1. I agree.
21. Electronic Signature*
22. Date Signed*
    Date Signed
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field