2. Roseville Fire Prevention Bureau
   Please complete this form for Roseville Fire Department use. This information will be kept on file for use in an emergency. When finished click submit at the bottom of the page. You may also choose to have an electronic copy emailed to you for your records.
4. Building Information
6. Building Name
8. Business Name*
10. Street Address*
11. Suite/Unit #
13. City
14. State
15. Zip Code
17. Correspondence Information
19. First Name*
20. Last Name*
22. Business Name
24. Street Address
25. Suite/Unit #
27. City
28. State
29. Zip Code
31. Work Phone
32. Cell Phone
34. Office Phone
35. Other Phone
37. Email
38. Alternate Email
40. Emergency Contact Information
42. First Contact Name*
43. Position
45. Work Phone*
46. Cell Phone*
48. Email
49. Key Holder*

    1. Yes

    1. No
51. Second Contact Name
52. Position
54. Work Phone
55. Cell Phone
57. Email
58. Key Holder

    1. Yes

    1. No
60. Third Contact Name
61. Position
63. Work Phone
64. Cell Phone
66. Email
67. Key Holder

    1. Yes

    1. No
69. Tennessen Notice:
    Some or all information you are asked to provide is classified by State law as either private, public, or confidential. The data will constitute a public record if and when the registration is granted. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information, the registration may not be issued.
71. Roseville Fire Prevention Bureau
    2701 Lexington Avenue N ▪ Roseville, MN 55113 ▪ Phone: 651.792.7340 ▪ Fax: 651.792.7300 fireinspections@cityofroseville.com
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73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

* indicates a required field