APPLICATION & RENEWAL FORM FOR SHORT TERM RENTAL PROPERTY
(In accordance with Black Jack Ordinance NO. 1108 Approved June 20, 2017)

THE APPLICATION FEE IS NON-REFUNDABLE*

INITIAL APP FEE - $200 ANNUAL REGISTRATION FEE - $100 (JULY 1 - JUNE 30)

BI-ANNUAL APP RENEWAL FEE - $50

THIS FORM MUST BE COMPLETED BY THE PROPERTY OWNER

SHORT TERM RENTAL PROPERTY ADDRESS*

OWNER'S NAME*

OWNER'S ADDRESS*

OWNER'S PHONE #*

OWNERS DRIVER'S LICENSE #/STATE*

LOCAL CONTACT PERSON IF DIFFERENT THAN THE INFORMATION PROVIDED ABOVE: (PERSON SHALL BE AVAILABLE 24/7 AND RESPOND WITHIN 45 MINUTES TO COMPLAINTS)

NAME

ADDRESS

PHONE #

DRIVERS LICENSE #/STATE

FACILITATION PLATFORM'S NAME:

FIRM NAME

ADDRESS

PHONE #

E-MAIL ADDRESS

WEBSITE ADDRESS

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I CERTIFY THAT I HAVE OBTAINED ANY AND ALL CONSENTS, AUTHORIZATIONS, VARIANCES, WAIVERS, LICENSES, PERMITS AND APPROVALS FROM ANY FEDERAL, STATE, COUNTY, MUNICIPAL OR OTHER GOVERNMENTAL OR QUASI-GOVERNMENTAL AGENCY, DEPARTMENT, BOARD, COMMISSION BUREAU OR OTHER ENTITY OR THIRD PARTY NECESSARY FOR THE OPERATION OF MY BUSINESS IN COMPLIANCE WITH ALL APPLICABLE FEDERAL, STATE AND CITY LAWS AND REGULATIONS, AND THAT I WILL OPERATE MY BUSINESS IN ACCORDANCE THEREWITH. I FURTHER UNDERSTAND THAT ANY FALSE STATEMENTS MADE ABOVE ARE GROUNDS FOR DENIAL, SUSPENSION OR REVOCATION OF THE SHORT TERM RENTAL PROPERTY PERMIT.

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FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS AREA

CITY OF BLACK JACK BUSINESS LICENSE # __________ EFFECTIVE__________ EXPIRATION__________

INSPECTION DATE:______________________________________________________________________________________________

INSPECTION'S NOTES:___________________________________________________________________________________________

PERMIT #__________EFFECTIVE__________EXPIRATION__________

# OF BEDROOMS _______ # OF ALLOWED GUESTS_______