City of Lakewood Rental Safety Program

First Name:

Business Name:

Last Name:

Primary Phone:

Mailing Address:

Cell Number:

City:

E-Mail Address:

State:

Password:

Zip:

Confirm password:

Note that passwords require the following:

Please make sure the information entered above is correct then check the following checkbox.

I certify that the above information is true and correct to the best of my knowledge.