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R CITY OF MAPLEWOOD <br /> • Citizen Services Department <br /> 1N/t 1 1;=L DIW C P2P 1830 County Road B East <br /> Thget arWeC� Maplewood, MN 55109 <br /> www.cimaplewood.mn.us 651-249-2003 Phone <br /> 651-249-2009 Fax ACTIVITY#: <br /> Registration No. Description Expiration Date <br /> RENEWAL NAME <br /> RENEWAL NAME2 <br /> RENEWAL ADDRESS <br /> RENEWAL ADDRESS2 <br /> Please complete the information below: <br /> Business Name: DBA NAME <br /> Address: DBA ADDRESS Contact Person: <br /> DBA ADDRESS2 <br /> Renewal Address: <br /> Business Phone: DBA PHONE NUMBER <br /> Daytime Phone: <br /> RENEWAL NAME ACTIVITY#: <br /> RENEWAL NAME2 Registration#: <br /> • <br /> RENEWAL ADDRESS <br /> RENEWAL ADDRESS2 Total Due • <br /> Amount due if not paid in full by the Due Date: <br /> CITY OF MAPLEWOOD <br /> CITIZEN SERVICES DEPARTMENT <br /> 1830 COUNTY ROAD B EAST <br /> MAPLEWOOD,MN 55109 <br /> FOR OFFICE USE ONLY <br /> • Receipt#: <br /> Date: <br /> PLEASE RETURN THIS ENTIRE FORM ALONG WITH YOUR PAYMENT <br />