Application for Campground License - Cheyenne Laramie County Public Health

License Fee:(Required)

New Facility: $190

Renewal: $95

LICENSE APPLICATION INFORMATION

(To be completed by applicant.)

Type of Application:(Required)

New

Change of Owner

Change of Location

Other

Form of Organization:(Required)

Individual

Association

Corporation

Partnership

Other Legal Entity

Other (specify):

Other Legal Entity (specify):

If Corporation/Business Entity is Required to be Registered, Name the State Where Incorporated/Registered:

Date Incorporated/Registered:

Establishment Information

Establishment Name:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Applicant Information

Owner's Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Please Indicate Where to Mail the License:(Required)

Establishment

Owner/Manager

Type of Establishment:(Required)

Temporary

Permanent

Number of Spaces:(Required)

I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED IN THIS APPLICATION. I AGREE TO COMPLY WITH ALL APPLICABLE CHEYENNE LARAMIE COUNTY PUBLIC HEALTH RULES AND REGULATIONS AND I UNDERSTAND THAT EACH SECTION OF THE RULES AND REGULATIONS IS SEPARATELY AND COLLECTIVELY ENFORCEABLE. I AGREE TO ALLOW THE REGULATORY AUTHORITY ACCESS TO MY FACILITY.

Applicant Signature(Required)

Draw your signature.

Date(Required)

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Approving Official

First Last