Convenience Store Registration

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Thank you for registering your convenience store with the Hurst Police Department. Before completing and submitting the form below, please watch this convenience store safety video produced by the Houston Police Department.

Please correct the fields below:

Please correct the field(s) marked in red below:

HURST POLICE DEPARTMENT

Convenience Store Registration Form

As required by City of Hurst ordinance number 2458, convenience stores are now required to register with the Hurst Police Department. All form questions are REQUIRED to be completed with the exception of a fax number.

Thank you for your submission.

Hurst Police Department

STORE INFORMATION

Store Name

Store Address

Store Phone Number

Store Fax Number

City

State

Zip Code

OWNER INFORMATION

First Name

Last Name

Street Address

OWNER CITY, STATE AND ZIP CODE

City

State

Zip Code

OWNER CONTACT INFORMATION

* Email address will be used to send registration information and updates*

OWNER CONTACT INFORMATION * Email address will be used to send registration information and updates*

Phone Number

Email Address

STORE OWNER (CORPORATION)

Enter NONE or N/A in required fields if your store is not corporately owner

Corp Contact First Name

Corporate Contact Last Name

Corporate Name

Corporate Contact Address

Corporate Contact City

Corporate Contact State

Corporate Contact Zip Code

Corporate Contact Phone

E-mail will be used to send registration information and updates

Email E-mail will be used to send registration information and updates

MANAGER / STORE OPERATOR INFORMATION

First Name

Last Name

Address

City

State

Zip Code

Manager Phone

24 Hour Contact Number

Email will be used to send registration information and updates

Email Email will be used to send registration information and updates

By entering your name below, you acknowledge that you have watched the Convenience Store Safety video above.

Name

I UNDERSTAND THAT THIS APPLICATION IS AN OFFICIAL GOVERNMENT RECORD. I UNDERSTAND THAT KNOWINGLY MAKING A FALSE ENTRY OR OMITTING REQUIRED INFORMATION IN ONE OR MORE OF THE ABOVE FIELDS COULD RESULT IN CRIMINAL CHARGES AND TEH DENIAL/REVOCATION OF MY REGISTRATION.

To receive a copy of your submission, please fill out your email address below and submit.
Email Address