CITY OF RICHMOND 
                            DIRECTOR OF FINANCE 
                                           P.O. Box 1268 
                            Richmond, Kentucky 40476-1268 
                            (859) 623-1000 ext. 2024 FAX (859) 624-2753 
 
Name of business or trade name:__________________________________________________ 
 
Business street address:_________________________________________________________ 
 
City, State, Zip:_________________________________________________________________ 
 
Mailing address:________________________________________________________________ 
 
City, State, Zip:_________________________________________________________________ 
 
Telephone number:(____)_________________Fax number(____)________________________ 
 
Owner’s name:_________________________________________________________________ 
 
Owner’s address:_______________________________________________________________ 
 
City, State, Zip:______________________________________Home phone:(____)___________ 
 
Date operations started in Richmond:_______________Approximate number of employees:____ 
 
Nature of business:______________________________________________________________ 
 
Type of Business:___Corporation____SCorporation____Partnership____Individual____Fiduciary 
 
____Farm____LLC____Religious or Not for Profit____Other(Please specify)________________ 
 
Federal EIN:______________________Social Security Number:__________________________ 
                                         st
Accounting Period:______Calendar year(December 31 ) _______Fiscal year(Month__________) 
 
List contact person(s) name(s)___________________________Telephone(____)____________ 
 
List previous owner’s name and address:____________________________________________ 
 
                                    _____________________________________________ 
 
ALL BUSINESSES: List all Subcontractors working under you on this or any job in the City of Richmond.(Attach additional 
sheets including: Name, Address, & Social Security Number) 
 
PARTNERSHIPS: List all Partners with Address and Social Security Information. (Use additional sheets) 
 
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is 
true, correct and complete. 
 
PLEASE REMIT A CHECK OR MONEY ORDER FOR $50.00 WITH QUESTIONAIRE. 
 
Signature:__________________________________________Title:______________________ 
 
Date:___________________________________ 

                                            CITY OF RICHMOND

                                     RICHMOND POLICE DEPARTMENT
                                            1721LEXINGTON ROAD
                                            RICHMOND, KENTUCKY 40475
                                            859-623-1162

                      Dear Business Owner:
Col. Larry R. Brock
Chiefof Police
                      The Richmond Police Department maintains notification listings for all businesses with a
Vacant                physical structure located within the city limits.  These listings are maintained by the
Asst. Chief of Police Madison County 9-1-1 Center so that we are able to contact a responsible party for the
MajorSteve Gregg      business in case of an emergency or other event that requires contactwith the
Patrol Division       owner/operator of the business. The information will be held in the strictest confidence.
MajorRobert Mott
Investigations        In order to provide the best service possible to your business, please provide the
                      information requested below.  Keep in mind that a representative for your business
Major Mitch Brown     should be a key holder and have the authority to allow either police officers, firefighters
Professional Develop.
                      or other emergency services personnel with access to the premises.

                      Business Name:  _____________________________________________________

                      Street Address:   _____________________________________________________

                      Telephone No.:    _____________________________________________________

                      Fax Number:       _____________________________________________________

                      Authorizedcompanyrepresentatives (list in orderto be contacted):

                                       Name                 ContactNumber(s)

                      1)___________________________________ ______________________________

                      2)___________________________________ ______________________________

                      3)___________________________________ ______________________________

                      4)___________________________________ ______________________________

                      5)___________________________________ ______________________________

                      Please notify us or the Madison County 9-1-1 Center (telephone #859-624-4776, Fax #
                      859-623-0926)of any changes to this notification listing.  Thank you for helping us to
                      serve you better.

                      Chief of Police