Dekalb County Business Registration Application printable pdf download

DEKALB COUNTY BUSINESS REGISTRATION APPLICATION

Internal Audit & Licensing, 330 W. Ponce De Leon Ave., Decatur Ga. 30031 (404) 371-2461 Fax (404) 371-2946 ACCOUNT #______________

OFFICE USE ONLY:

NAICS ________ Class ________ Type ________ H.O.P. ________ District ________ Lot ________ Block ______ Parcel _______

Zoning:

Approved by___________________ Denied by _________________ Date __________ Denial Reason_______________________________________

Pending Items: C.O. ___ Fire ____ Health ____ Sanitation Service _____ State License _______ Insurance (Taxi/Limos) _______ Police _________ Other _________

Business License Items: Primary ID#____________________ Owner’s ID#_______________________ Bill To ID#_______________________

Type or Line(s) of Business to be conducted: ________________________________________________________________________________________

Applicant’s Name ____________________________________ Title:_________

Business /Trade Name _________________________________________________

Ownership Type: Single Owner/Sole Proprietor ______

Partnership ______

Street Address: ______________________________________________________

Owner(s) Name: ___________________________________________________

City/State/Zip _______________________________________________________

Ownership Type :

Association ___ Corporation ___ LLC ____

Business Telephone # _________________________________________________

E-Mail : ____________________________________________________________

Corporate or LLC Name: ____________________________________________

Bill To/Mailing Name: ________________________________________________

State Where Incorporated: __________________

Date Inc: ___________

Bill To /Mailing Address: ______________________________________________

Agent’s Name: ______________________________________ Title:________

Owner/Agent’s Home Address: ______________________________________

City/State/Zip: _______________________________________________________

Owner/Agent’s City/State/Zip: _______________________________________

Applicant’s must provide copies of driver’s license or other

Owner/Agent’s Telephone (Home No.): ________________________________

Governmental Issued Photographic Identification with Application

DeKalb County Sanitation Account Number: _______________________ Private sanitation service name: ______________________________________

Will business be based out of your home? Yes____ No____. If yes, is a “Home Occupation Supplemental Registration Form” included? Yes____ No____

Will your business be an adult entertainment establishment (sexually oriented business) as defined by the DeKalb County Code or does (will) it offer any

form of adult entertainment? Yes__________ No___________

See reverse side of this form for Code definitions.

Has the owner, applicant, the stated business, or any legally or organizationally related entity had a business occupation tax certificate denied, suspended,

or revoked within the past twelve (12) months? Yes ________ No _________. If yes, attach written explanation.

Georgia Open Records Act prohibits public viewing of gross receipts & number of employees. The public may view other information on this form.

DeKalb plus Georgia Gross Receipts (estimate)

$___________________________X ____________________

$_________________________

Employee Fee (at least one, includes owner/operator)

#___________________________ X ____________________

$ ________________________

Flat Fee of $50.00. (except for professionals paying optional $400)

$50.00

Administrative Fee (no refund or transfer)

$75.00

Total Amount Due or Professional Option. ($400 per practitioner by O.C.G.A.)

$ _________________________

This application must be executed under oath and notarized. I, ______________________, do solemnly swear that the information on this application is

true, and that no false or misleading statement is made herein to obtain a business occupation tax certificate. I understand that if I provide false or misleading

information in this application I may be subject to criminal prosecution and/or immediate revocation of my business occupation tax certificate issued as a

result of this application. I understand that I must comply with all county ordinances and regulations. I hereby agree to provide clearance(s) and/or inspection

report(s) required prior to issuance of a business occupation tax certificate. All tax certificates expires December 31 and must be renewed annually

Signature __________________________________________ Position _______________________________ Date ____________________________

Sworn to and subscribed before me this ____________________ day of ________________________________, 20 ___________.

Notary Public Signature _______________________________________