Convenience Store Registration Form

Houston Police Department

The date and time of your submission is automatically generated when you click SUBMIT. Please complete all fields.

STORE INFORMATION
Check One:	New Application or Updated Application
Store Name:
Store Address:
Store Phone:
Fax:	-- if none, write none
City:
State:
Zip Code:

STORE OWNER OR PRINCIPAL PROPRIETOR
First Name:
Last Name:
If Corporation, Name:
Address:
City:
State:
Zip Code:
Phone:
Please list below the nature and extent of the owner's interest in the property. If there is only one owner, the extent of the owner's interest is 100%

MANAGER OR CONTACT PERSON'S INFORMATION
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Store Phone:
E-Mail Address:

REGISTERED AGENT
If registered agent is not applicable Please type in None in the following fields.
Corporation Name:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Store Phone:
E-Mail Address:

I understand that this application is an official government record. I understand that knowingly making a false entry or omitting required information in one or more of the above fields could result in criminal charges and the denial / revocation of my registration.