PRIVILEGE LICENSE APPLICATION THIS APPLICATION REQUIRED BY LAW MUST

privilege license application this application required by law must be completed & all questions answered (minimum 24 hour wa

PRIVILEGE LICENSE APPLICATION
THIS APPLICATION REQUIRED BY LAW
MUST BE COMPLETED & ALL
QUESTIONS ANSWERED
(MINIMUM 24 HOUR WAITING PERIOD)
_________________________
ACCOUNT NUMBER
_________________________
DATE OF APPLICATION
BUSINESS NAME ______________________________________ OWNER’S NAME
____________________________________
BUSINESS ADDRESS ___________________________________ SOCIAL SECURITY #
________________________________
MAILING ADDRESS ____________________________________ HOME ADDRESS
____________________________________
____________________________________
____________________________________
BUSINESS TELEPHONE _________________________________ HOME TELEPHONE
_________________________________
TYPE OF BUSINESS
HOME OCCUPATION: YES / NO OWN ___________ RENT ____________
PARTNERSHIP __________ CORPORATION __________ INDIVIDUAL __________
TRANSIENT VENDOR __________
WHOLESALE _______ MANUFACTURING _______ SELLING _______ SERVICE
_______ RETAIL _______
NAME OF PARTNERS
_______________________________________________________________________________________
(IF PARTNERS, PLEASE LIST NAMES & SOCIAL SECURITY NUMBERS)
WHEN WILL/DID YOU BEGIN OPERATION OF YOUR BUSINESS IN THE CITY?
____________________________________
KIND OF BUSINESS (PLEASE BE SPECIFIC)
____________________________________________________________________
STATE TAX ID NUMBER __________________________________ (ATTACH COPY OF
YOUR PERMIT FROM THE STATE
FEDERAL TAX NUMBER __________________________________ TAX COMMISSION)
SALES TAX NUMBER _____________________________________
DO YOU CONFORM TO ALL GUIDELINES SET BY STATE STATUE?
______________________________________________
LICENSE MUST BE RENEWED AND PAYMENT RECEIVED BY DECEMBER 31ST OF EACH
YEAR TO AVOID 10% PENALTY, THE FIRST MONTH, AND THEREAFTER, A PENALTY
OF ONE PERCENT (1%) PER MONTH OR PART THEREOF DURING WHICH THE TAX
REMAINS DELINQUENT.
TOTAL NUMBER OF FULL-TIME EMPLOYEES _________________ FOR THE PAST 12
MONTHS. NOTE: THE TERM “EMPLOYEE” MEANS FULL-TIME EMPLOYEES AND, WITH
RESPECT TO A PROFFESSIONAL FIRM OR CLINIC, ALSO INCLUDES ALL PARTNERS;
HOWEVER, SUCH TERM EXCLUDES SEASONAL EMPLOYEES. THE TERM “FULL-TIME”
MEANS AT LEAST THIRTY (30) HOURS PER SEVEN-DAY WEEK.
WHOLESALE-RETAIL
AMOUNT OF ASSESSED INVENTORY (TO THE NEAREST DOLLAR)
______________________________________________
DO YOU SELL BEER? (ATTACH COPY OF STATE BEER PERMIT)
_________________________________________________
DO YOU OWN AMUSEMENT MACHINES?
_____________________________________________________________________
TOBACCO TAX (DO YOU SELL TOBACCO PRODUCTS?)(ATTACH COPY OF STATE
TOBACCO PERMIT) _____________
DO YOU SELL FOOD? (ATTACH COPY OF YOUR FOOD PERMIT FOR THIS LOCATION)
____________________________
DO YOU HAVE VENDING MACHINES? _______________________ IF SO, HOW MANY?
______________________________
AFFIDAVIT
I HEREBY CERTIFY THAT ALL INFORMATION GIVEN ON THIS APPLICATION FOR
THE PURPOSE OF SECURING A PRIVILEGE LICENSE, AND DETERMINING THE
AMOUNT DUE, IS TRUE AND CORRECT.
SIGNATURE ________________________________________ TITLE
______________________________ DATE _____________
THIS SPACE FOR USE BY TAX COLLECTOR
NEW ________________________________ LICENSE FEE
_____________________________________
RENEWAL ___________________________ OTHER FEES
______________________________________
NAME CHANGE ______________________ TOTAL AMOUNT DUE
_____________________________