Forms • Black Jack, MO • CivicEngage

VACANT PROPERTY REGISTRATIN REQUEST FORM

Leave This Blank:

DATE*		INSPECTION DATE*
REPORTED BY*
PROPERTY ADDRESS*		BLACK JACK, MO 63033
HOUSING CODE VIOLATIONS FOUND ON THE PROPERTY*
PROPERTY OWNER NAME*
ADDRESS*
PHONE*		EMAIL*
LOCAL PROPERTY MANAGEMENT COMPANY
NAME OF CONTACT
ADDRESS
PHONE		EMAIL
SEMI-ANNUAL REGISTRATION FEE - $200

* indicates required fields.