Convenience Store Registration Form

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POLICE Department

Convenience Store Registration Form.

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

STORE INFORMATION
* Store Name:
* Sales Tax Number:
*Store Address:
*Store Phone:
Fax:
* City:
* State:
* Zip Code:

STORE OWNER (INDIVIDUAL)
* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip Code:
* Phone:
Email:	E-mail will be used to send registration information and updates

or STORE OWNER (CORPORATION) Enter NONE or N/A in required fields if your store is not corporately owned
* Corp Contact First Name:
* Corp Contact Last Name:
* Corp Name:
* Corp Contact Address:
* Corp Contact City:
* Corp Contact State:
* Corp Contact Zip:
* Corp Contact Phone:
Email:	E-mail will be used to send registration information and updates

MANAGER / STORE OPERATOR INFORMATION
* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip Code:
Manager Phone:
* 24 Hour Contact Number:
Email:	E-mail will be used to send registration information and updates

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.

Houston Police Department

POLICE Department

Convenience Store Registration Form.

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