2. Register Your Business
4. Business Name*
6. Doing Business as (if Different)
8. Business Address*
10. City*
11. State*
12. Zip Code*
14. Mailing Address (if Different)
16. City
17. State
18. Zip Code
20. Telephone Number*
    example: (612) 555-1234
22. Fax Number
    example: (612) 555-1234
23. Primary Contact Email address*
25. Date of Illinois Secretary of State Registration
    example: 12/27/1987
26. Business Opening Date*
    Business Opening Date
    Please let us know when the business opened or the projected date of opening.
28. Tax Identification Number*
    example: 12-3456789 If not applicable, please enter zeros
29. Illinois Sales Tax/Business Registration Number*
33. Business Type (Select One)

    1. Sole Proprietor
    2. Corporation
    3. Partnership
    4. Other
34. Business Category*
    -- Select One --Accounting, Auditing, BookkeepingAmusement & RecreationAnimal Specialty ServicesApartments & TownhomesArchitectural ServicesAsphalt Paving & ContractingAuto Repair & Paint ShopsAutomotive Repair ShopsBakeriesBanquet VenuesBarber ShopsBars, Lounges & TavernsBeauty ShopsBeer, Wine & Beverage DistributorsBotanical & Zoological GardensBrick & Structural Clay TileBusiness ConsultingBusiness OrganizationsBusiness ServicesCarwashesCateringChiropractorsChurches & Religious OrganizationsCivic & Social OrganizationsClothing StoresColleges & UniversitiesCommercial BanksCommunications ServicesComputer Integrated SystemsComputer Maintenance & RepairComputers & SoftwareContractorsCosmetics & Beauty ProductsDentistsDepartment StoresDistribution Centers, Warehousing & StorageElectric Supply & UtilitiesElectricians & Electrical ContractingElementary & Secondary SchoolsEmployment AgenciesEngineering ServicesEquipment Rental & LeasingFederal Credit UnionsFloristsFoundations/Educational & Charitable TrustsFuneral Service & CrematoriesFurniture StoresGas Stations & Convenience StoresGovernmentGraphic DesignGrocery StoresHealth & Allied ServicesHome FurnishingsHome Health Care ServicesHotels & MotelsHousehold Appliance StoresIndividual & Family OrganizationsInsurance Agents, Brokers & ServicesInvestment ServicesJanitorial & Cleaning ServicesJewelry StoresLawn, Garden & Landscaping ServicesLegal ServicesLibrariesLoan BrokersLocal TruckingLumber & Other Building MaterialsMarketing & Public Relations FirmsMedical & Surgical HospitalsMuseum & Art GalleriesMusic StoresNewspapers & Media (Print & Online)Non-Profit OrganizationsOptometristsPaint, Glass & WallpaperPersonal ServicesPhotographic Studios, PortrairPhysical Fitness FacilitiesPhysicians & Medical DoctorsPlumbing, Heating & A/CPrivate HouseholdsPublishing & PrintingReal Estate & Land DevelopersReal Estate Agents & ManagersRecreationRecyclingRestaurants & CateringRetailRoofing, Siding & Sheet Metal WorkSchools & Educational ServicesScreen Printing & Promotional ItemsSecurity Systems ServicesShoe StoresSign Manufacturing & FabricationSingle Family HousingSkilled Nursing Care FacilitiesSports ClubsTax Return Prep ServicesTelephone CommunicationsTermite, Pest Control & Extermination ServicesTitle Abstract OfficesTravel AgenciesVeterinary ServicesWatch, Clock & Jewelry RepairWebsite DevelopmentOther
38. Owners & Officers
40. Name Number 1*
42. Phone Number*
    example: (612) 555-1234
44. Cell Phone Number
    example: (612) 555-1234
46. Street Address*
48. City*
49. State*
50. Zip Code*
52. Name Number 2
54. Phone Number
    example: (612) 555-1234
56. Cell Phone Number
    example: (612) 555-1234
58. Street Address
60. City
61. State
62. Zip Code
64. Name Number 3
66. Phone Number
    example: (612) 555-1234
68. Cell Phone Number
    example: (612) 555-1234
70. Street Address
72. City
73. State
74. Zip Code
78. Planning & Zoning
80. Will Business Signs Be Displayed?*

    1. Yes
    2. No
82. Is This a Home Based Business?*

    1. Yes
    2. No

    If yes, call 618-692-7535 and a Planning & Zoning staff member will assist you.
86. Safety
    This information is provided to the Edwardsville Police Department for Emergency and Safety purposes only.
88. Emergency Contact
90. Name & Title Number 1*
92. Phone Number*
    example: (612) 555-1234
94. Name & Title Number 2
96. Phone Number
    example: (612) 555-1234
98. Name & Title Number 3
100. Phone Number
     example: (612) 555-1234
104. Does Business Have a Commercial Burglar / Fire Alarm?

     1. Yes
     2. No
105. Does the business have a video security system?

     1. Yes
     2. No
107. Alarm Company Name
109. Phone Number 1
     example: (612) 555-1234
111. Phone Number 2
     example: (612) 555-1234
113. Street Address
115. City
116. State
117. Zip Code
121. Alarm Type (Mark All That Apply)

     1. Silent
     2. Burglary
     3. Robbery
     4. Fire
     5. Local
     6. Regular
     7. Automatic
     8. Dialer
     9. Other
125. Connections to (Mark All That Apply)

     1. Residents
     2. Alarm Company
     3. Private Security
129. Does business have a safe?

     1. Yes
     2. No
131. If Yes, Location of Safe:
Leave This Blank:


133. 1. Receive an email copy of this form.
134. Email address

     This field is not part of the form submission.

135. Submit

* indicates a required field