Management Company Name: _______________________________________________________________________

         Street Number and Street Name

Business Hours Phone Number:_______________________ Emergency Phone Number:____________________
                                                       include area code                                                            include area code

Fax Telephone:________________________   Email Address:___________________________________________
                            Include Area Code

Pool Name:________________________________________________  Pool Telephone:___________________
                                                                                                                                                  include area code

Pool Address:_______________________________________________________________________________
                                    City                                                                        State                                        Zip Code           

Pool Management Company Representative Responsible for this facility:

            Name:____________________________________________  Phone Telephone:____________________
                                                                                                                                                  include area code

            Fax Telephone:_____________________ Email Address: ______________________________________
                                        include area code         

Date individual was notified or will be notified regarding this assignment:_________________

(Note: Pool Management Company must notify the Office of Licensure and Regulatory Services within48 hours of any change in responsible personnel.)

Pool Management Company responsibilities: (Check all that apply).

         Assuring compliance with all operating standards set forth in Chapter 51 of the Montgomery County Cope and all rules and regulations promulgated hereunder.
         Providing for the physical maintenance, supplies and personnel as required by Chapter 51 and all rules and regulations promulgated hereunder.
       Obtaining all necessary permits and licenses.

Payment Method:   Fee Information: $50.00 per facility

Check Money Order (No cash is accepted) Visa Mastercard  (No other credit cards are accepted )

Organization: _________________________________Cardholder’s Name:______________________________

Credit Card No:_________________________________ Exp. Date:______________  Amt: $_______________

I agree to pay the above total amount according to the card issuer agreement.

 Cardholder’s Signature: _______________________________________________________

Submit completed application and application fee to address at the top of the application. Checks or money orders are payable to “Montgomery County, Maryland”.