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Baytown Custodial Residential Care and Living Permit Application

2. Facility Name*
4. Facility Physical Address*
6. City
7. State
8. Zip Code
10. Facility Mailing Address
12. City
13. State
14. Zip Code
16. Facility Main Phone Number*
17. Facility 24-hour Emergency Phone Number*
19. Facility Administrator*
21. Office Number*
22. Mobile Number*
24. Email Address
26. Driver's License Number and State*
28. Number of Occupants*
30. Description of Services Provided*
32. Facility Owner/Parent Company Name*
33. Principal Title*
35. Address
37. City
38. State
39. Zip Code
41. Phone Number
43. I hereby apply for a Baytown Custodial Residential Care and Living Permit. I attest that the information contained in this application is true and accurate to the best of my knowledge.
45. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*

    1. I Agree
47. Electronic Signature of Person responsible for this Facility:*
48. Date*
    Date
50. This application must be submitted and a check made payable to the City of Baytown in the amount of $50 for new facilities and $25 for renewals must accompany the Baytown Facility Emergency Operations Plan. Submit Custodial Care Permit payments online. Submit Forms and Plans via email to OEM@baytown.org
51. Online Payment
    Online Custodial Care Payment
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field