052cl002 - License Processing Form
ADVERTISEMENT
1City of Mobile
License Processing Form
License Year: _________ Account #: _____________ Postmarked: _____________ Territory: ______
LICENSE
GROSS
LICENSE
PENALTY
INTEREST
TOTAL DUE
CODE
AMOUNT
AMOUNT
AMOUNT
AMOUNT
PER CODE
_________
__________
__________
__________
___________
____________
_________
__________
__________
__________
___________
____________
_________
__________
__________
__________
___________
____________
_________
__________
__________
__________
___________
____________
_________
__________
__________
__________
___________
____________
ADD
INCEPTION
GROSS
PENALTY
INTEREST
TOTAL DUE
CODE
DATE
AMOUNT
AMOUNT
AMOUNT
PER CODE
________
__________
____________
____________
___________
____________
________
__________
____________
____________
___________
____________
________
__________
____________
____________
___________
____________
________
__________
____________
____________
___________
____________
PLEASE CHECK THE APPROPRIATE BOX WHEN ADDING CODES:
SIXTY DAY STATEMENT GIVEN?
YES
NO
ZONING FEE ____________
ISSUE FEE
____________
TOTAL PAID ____________
I certify under oath that the gross revenues reported hereon include and represent the total volume of
business without any deductions of any kind.
X_____________________________________________
_______________________
Signature of Account Representative
Date Form Signed
______________________________________________
Company Name
_______________________________________________
Address
_______________________________________________
City / State / Zip
Employee's Initials / Emp. # :
_________ / _______
(Please Write Any Comments On Back Of Form)
052CL002
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business