License Information Request Form - Government Of The District Of Columbia
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1
2Government of the District of Columbia
DEPARTMENT OF CONSUMER AND REGULATORY AFFAIRS
OFFICE OF INFORMATION SYSTEMS
941 North Capitol Street, N.E., Suite 3600
WASHINGTON, D.C. 20002
LICENSE INFORMATION REQUEST FORM
Customer Name:________________________________________________________________
Customer Address:______________________________________________________________
Customer Telephone:____________________________________________________________
Information Medium Requested
¨ Printout
¨ Labels
¨ Diskette
NOTE! – We can also email the information or FTP it directly to your site. Please supply the correct
information below (or call us at 202-442-8348)
¨ email
¨ FTP
Host Name
______________________________________________
Host Type
______________________________________________
User ID (or Anonymous)
__________________________________
Password
______________________________________________
Account No. ______________________________________________
License Category of Information Requested:__________________________________________
(Please submit a separate Request Form for each listing requested)
Indicate below by inserting a number (1, 2, or 3) after the corresponding information field, the sort order in
which you would like the information returned. Circle the additional fields you wish to be included in your
report. (Maximum of three sorts)
Licensee Name _________
License Number _________
Premise Quadrant _________
Business Quadrant _________
Premise Ward _________
Business Ward _________
Premise Street _________
Business Street _________
Premise Address _________
Business Address _________
Premise Zip Code _________
Business Zip Code _________
(Please note that business address information may be incomplete)
Customer Signature: __________________________________ Date of Request: ____________
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Parent category: Legal