Form Center

2. Name of Location
3. Type of Location

   Home, Business, Apartment, etc.

5. Location Address
6. Zip Code
8. Company Name (if applicable)
10. First Name*
11. Last Name*
13. Mailing Address
15. City
16. State
17. Zip
19. Business Phone
20. Fax
21. Home Phone
22. Cell Phone
24. Email Address
26. I certify that I have the aurhtority to file such paperwork with the Centralia Police Department as the:*

    1. Owner

    1. Lessee

    1. Manager

    1. Other

28. By submitting this document I do hereby designate each and every police officer now or hereafter employed by the City of Centralia as agent for the purpose of enforcing Section 9.10.140 of the Centralia Municipal Code and RCW's 9A.52.070, 9A.52.080, 9A52.010(3), 9A.52.105 and 9A.52.115. This authorization shall continue in full force and effect until such time as it is revoked in writing and said writing is duly delivered to the Centralia Police Department.

30. I have read and understand the above.*

    1. Yes
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

* indicates a required field