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Private Provider Registration

  1. All Private Provider organizations must register with the City of Jacksonville Beach and shall be responsible for keeping their information continuously maintained.

  2. Registration Type*
  3. Same Mailing Address?*
  4. NOTE: E-mail hosts for some webmail accounts (including but not limited to BELLSOUTH and/or AT&T) may block e-mails generated from the City Domain. If you experience issues or do not receive a response within 5 business days, please contact your service provider for assistance.  You may want to enter a secondary e-mail address hosted by a separate domain (provider).

  5. A screen print from the licensing authority is acceptable.

  6. Leave This Blank:

  7. This field is not part of the form submission.