Application For Transient (Temporary) Privilege Tax License (Arizona) - 2011 Page 4
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2
3
4Revenue Collections Operations
Mailing Address
Licensing Office
PO Box 1466
55 North Center Street
Mesa Arizona 85211-1466
Mesa, AZ 85201
(480) 644-2316 Phone
F o r O f f i c e U s e O n l y
(480) 644-3999 Fax
A p p . F e e
APPLICATION FOR TRANSIENT (TEMPORARY) PRIVILEGE TAX LICENSE
NON-REFUNDABLE $30.00 DUE AT THE TIME OF APPLICATION
L i c e n s e F e e
Start Date of Activity
This license will be good for 30 days from
start date of activity.
L i c e n s e #
SECTION I. BUSINESS INFORMATION
Business Name: Company, "DBA", or Individual
Office Use Only
S I C C o d e
Business Address
License #
B u s i n e s s C l a s s
City
State
Zip
G e o C o d e
Name of Event (if applicable)
F i l i n g F r e q .
Event Address (if applicable)
State
Zip
NAICS Code
I n i t i a l s
Business Phone Number
E-mail address
Z o n i n g
Cell Phone Number
Initials
A p p r o v e d
SECTION II. MAILING ADDRESS
D e n i e d
Name
C o m m e n t s
Mailing Address
State
Zip
City
SECTION III. BUSINESS OWNERSHIP & RECORD LOCATION
Other _______
Individual
Corporation - State ______
Partnership
LLC
Ltd. Partnership
Ownership:
Name
Title
Owners, Partners,
LLC Members, or
Home Address
Social Security #
Officers
(For Additional Names,
Phone No.
City
State
ZIP Code
Please Attach List)
(
)
Name
Title
Home Address
Social Security #
B u s i n e s s N a m e ( I n d i v i d u a l , C o m p a n y o r " D B A " , f i r s t n a m e f i r s t )
City
State
ZIP Code
Phone No.
(
)
S t r e e t N o . ( N , E , S , W ) S t e / A p t #
T y p e
S t r e e t N a m e
Name
Phone No.
Location Where
- -
(
)
Business Records
C i t y S t a t e
Z I P C o d e + 4
A r e a C o d e B u s i n e s s T e l e p h o n e #
State
Address
City
ZIP Code
Are Kept
-
F e d e r a l I D # S t a t e L i c e n s e #
Section IV. Business Activity
Describe Type of
Inventory Sold
I certify that the statements made in this application are true and complete to the best of my knowledge. I accept the license authorized and issued in
response to this application with the condition that I report timely and pay any and all taxes due by me to the city.
Print Name
Signature
Title
Date
Oct 2011
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