Complete this form and return it to City Hall at 459 Pine Drive, or mail to PO Box 1325, Pine Lake GA 30072. If you are not a property owner, please include proof of residency.
Date _________________________
Name __________________________________________________________________
Street address: ______________________________________ PO Box ________
Phone number: __________________________ Work: _______________________
Renters complete next two lines
Owners name: __________________________________________________________
Owners phone: __________________
Date lease expires: __________________
PUBLIC SERVICE INFORMATION
Occupants:
1. __________________________________ Age _________ DOB ______________
2. __________________________________ Age _________ DOB ______________
3. __________________________________ Age _________ DOB ______________
4. __________________________________ Age _________ DOB ______________
5. __________________________________ Age _________ DOB ______________
6. __________________________________ Age _________ DOB ______________
Emergency contact: ____________________________________________________
Address: ____________________________________________ Zip _____________
Phone number: ____________________________ Relationship _______________