Application For Starting A New Home Based Business Form - County Of York, Virginia

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COUNTY OF YORK
Acct#: ________________
NEW HOME BASED
APPLICATION FOR STARTING A
BUSINESS
Date
Commissioner of the Revenue * Zoning & Code Enforcement * Building Regulations * Fire & Rescue
Received:___________
(757) 890-3383
(757) 890-3524
(757) 890-3522
(757) 890-3600
Type of Ownership:
Individual
Partnership
Corporation
Limited Liability Corp.
Applicant/Owner:
__________________________________________________________________________________________________________
(BASED ON OWNERSHIP)
Trade Name:
___________________________________________________________________________________________________________
Mailing Address:
___________________________________________________________________________________________________________
Suite No.
Street No./Name
P. O. Box
___________________________________________________________________________________________________________
City
State
Zip Code
Business Address:
___________________________________________________________________________________________________________
Street Number
Unit
Street Name
Date Business Established in York County: __________________________________
MM-DD-YYYY
Federal I.D. # ______________________________
State I.D. # ___________________________ Social Security # ____________________________
Email Address:
_______________________@________________________________ Website Address:_______________________________________
Local Business Phone: (
) ________ - ______________ Corp./Main Office Phone: (
) ________ - ______________
Cell Phone: (
) ________ - ______________
Fax Number: (
) ________ - ______________
Detailed Description of ALL Proposed Business Activities- if your business activity changes after the initial application, contact the office of the
Commissioner of the Revenue prior to initiating the change to determine if it affects your business classification:
_________________________________________________________________________________________________________________________________________________________________________________
EXAMPLE: CONTRACTOR-Painting; REPAIR-Auto; CONSULTANT-Computer; RETAIL-Beauty Products
Applicant/Ownership Information
List below, attach list or use the back of this application to identify the Owner, Partners or Officers of the above Company.
Proof of Identification:
NAME _________________________________________________
SSN: ____________________________
________________________
Home Address: _____________________________________ Home Phone: ____________________________
:_______________
Valid through
Proof of Identification:
NAME _________________________________________________
SSN: ____________________________
________________________
Home Address: ______________________________________ Home Phone: __________________________ _
:_______________
Valid through
TAX ASSESSMENT
ESTIMATED GROSS RECEIPTS
(Rounded)
FEE
TAX
FLAT FEES
TOTAL DUE
$_____________________________
$___________________________
$___________________________
+
$_________________
=
$___________________________
FILING PERIOD ESTIMATE: ___________________________________ THROUGH ____________________________________
MM-DD-YYYY
MM-DD-YYYY
OATH: I the undersigned applicant do swear (or affirm) that the foregoing figures and statements are true, full and correct to the best of my knowledge and
belief, and that I understand the limits of this license.
.
Applicant(s) Signature: ___________________________________________________________________________ Date: __________________________
The completion of this application and payment for county business license shall not be deemed to be approval to prosecute any business
without first obtaining Zoning and Use Permits, Required Building Inspections and Fire/Rescue Inspections for the location in which you intend to
locate.
(Commissioner of the Revenue – Application for a New Home Based Business)

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