Forms • Hagerstown, MD • CivicEngage

Operator License Designated Agent

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License ID #*

Name*
Address
City
State
Zip
Primary Phone #*
Secondary Phone #
Fax
Email*

	By checking this box I hereby acknowledge my obligations and responsibilities pursuant to Chapter 95 and 197 of the City Code, a fair summary of which have been provided to the undersigned landlord or designated agent.*

* indicates required fields.