West Wyoming Borough Landlord Registration Application

West Wyoming Borough

Landlord Registration Application

This form must be completed by Landlords, pursuant to Borough Ordinance (Ordinance 5-2015 Amended Landlord Registration) to register each building within West Wyoming Borough that contains rental dwelling units. A separate form must be completed for each building containing more than one rental unit. This form must be completed legibly in its entirety.

Property Address to Register: __________________________________________________________________________________

Landlord’s Name: ____________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City, State, Zip _______________________________________________________________________________________________

Phone #:_________________________________ Cell #:______________________________ Email: __________________________

Property Manager’s Name:_____________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City, State, Zip _______________________________________________________________________________________________

Phone #:_________________________________ Cell #:______________________________ Email: __________________________

Tenant’s Name: ______________________________________________________________________________________________

Phone #:_________________________________ Cell #:______________________________ Email: __________________________

Date Current Occupied Unit: _________________________ Total Number of Occupants: ________
Names: ____________________, ___________________, _____________________, _____________________, ________________
Habitable Rooms: □ Living Room □ Kitchen □ Dining Room □ Bath □ Bedroom #1 □ Bedroom #2 □ Bedroom #3

□ Other _____________________ □ Other: __________________ □ Other _____________ □ Other _____________________ □ Other: __________________ □ Other _____________

Note to applicant: Any person who submits false information, documentation or identification in connection with the Landlord’s registration shall pay a minimum fine of $300.00, plus court cost for the first offense, a minimum of $600.00 for the second offense, and a minimum fine of $1000.00 for each offense thereafter. In addition, any person who submits a false certification of documents shall be subject to a citation under this Ordinance.

I, ___________________________________________________, verify the facts set forth by me are true and correct to the best of my knowledge.

Borough Use Only

Received By: _____________________________________________ Date: __________________________________

Signature of Applicant: ___________________________________________________________________ Date: _____________________________