BUSINESS REGISTRATION FORM (Please print/type)
Initial Business Registration Annual Renewal with changes
BUSINESS INFORMATION:
Address: Business Name:
Business Name:
Business Name:
Business Name:
Per LMC Chapter 5.52.050 Multiple Businesses at the same address operated by the same owner need only file one form but clearly
identify all business names.
BUILDING OWNER INFORMATION:
Name:
Date:
Mailing Address:
Daytime Phone: Evening Phone: Email Address:
Fax Number:
BUSINESS OWNER INFORMATION:
Name:
Date:
Mailing Address:
Daytime Phone: Evening Phone: Email Address:
Fax Number:
BUSINESS OPERATIONS:
Business Hours Start/End: Number of Shifts: Number of Shifts: Number of Shifts:
Business Days (Circle):
M T W TH F S SU
Shift Start & End Times:
Shift Start & End Times:
Shift Start & End Times:
BUSINESS DESCRIPTION:
By checking this box, I acknowledge the above information may be beneficial to others and hereby
grant the City of Lebanon permission to disclose the above information to outside parties.
Citizen Services & Development Center
925 Main Street
Lebanon, OR 97355-3211
(541) 258-4912 (541) 258-4955 Fax
Email: busreg@ci.lebanon.or.us
Web: www.ci.lebanon.or.us
CONFIDENTIAL EMERGENCY INFORMATION
Information listed below is considered confidential and will only be provided to Police and Fire Personnel
EMERGENCY CONTACTS
(Please list 3 contacts that reside closest to the business):
SECURITY SYSTEM INFORMATION (If you have a security alarm system and/or security guards, please provide contact
information):
Alarm Company Name: Phone:
Guard Name: Phone:
Guard Name: Phone:
Guard Name: Phone:
ELEVATOR INFORMATION (If you have an elevator in the building, please provide contact information):
Elevator Company’s Name: Phone:
MATERIALS STORED ON PREMISES (Emergency personnel should be made aware of materials that could be
considered dangerous; please provide a list of any materials stored on the premises such as oxygen tanks, welding
equipment, flammable materials, chemicals, etc.
Material: Location:
Authorized Signature: Date:
Print Name Here: Telephone:
FOR OFFICE USE ONLY
Date Received: Fee Amount: Date Data Processed:
Staff Initials: Receipt No.: Processed by:
1
Name: Daytime Phone: Evening Phone:
2
Name: Daytime Phone: Evening Phone:
3
Name: Daytime Phone: Evening Phone:
PRINT
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