Business License Application Affidavit Form - Confidential - City Of Alhambra, California

A

City of Alhambra

Business License Section

BUSINESS LICENSE APPLICATION

111 South First Street, Alhambra, CA 91801

City of

Telephone: (626) 570-5021

lhambra

AFFIDAVIT – CONFIDENTIAL

CITY LICENSE NUMBER

Gateway to the

San Gabriel Valley

PLEASE TYPE OR PRINT CLEARLY, USING INK, ALL SECTIONS MUST BE COMPLETED

BUSINESS NAME

BUSINESS PHONE

STARTING DATE

BUSINESS ADDRESS

STREET

CITY

STATE

ZIP

MAILING NAME, IF DIFFERENT FROM ABOVE

MAILING ADDRESS, IF DIFFERENT FROM ABOVE

CITY

STATE

ZIP

TYPE OF OWNERSHIP

r SOLE PROPRIETORSHIP

r PARTNERSHIP

(IF SOLE PROPRIETORSHIP OR PARTNERSHIP YOU MUST LIST THE SOCIAL SECURITY

NUMBER OF EACH OWNER IN "OWNERSHIP" INFORMATION BELOW)

r CORPORATION

(IF YOUR BUSINESS IS INCORPORATED YOU MUST LIST FEDERAL ID NUMBER BEFORE COMPLETING THE NEXT SECTION BELOW)

FEDERAL ID NUMBER

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THIS SECTION MUST BE COMPLETED

LIST FULL LEGAL NAME, SOCIAL SECURITY NUMBER, TITLE, HOME ADDRESS AND HOME PHONE NUMBER OF EACH OWNER OR CORPORATE OFFICER.

ATTACH ADDITIONAL SHEET IF NECESSARY.

NAME

SOCIAL SECURITY NUMBER

TITLE

HOME PHONE

HOME ADDRESS

APT. NO.

CITY

STATE

ZIP

NAME

SOCIAL SECURITY NUMBER

TITLE

HOME PHONE

HOME ADDRESS

APT. NO.

CITY

STATE

ZIP

TYPE OF BUSINESS [CHECK WHICHEVER IS APPROPRIATE]

r RETAIL

r WHOLESALE

r SERVICE

r IMPORT/EXPORT

r MANUFACTURING

r PROFESSIONAL

r ENTERTAINMENT

(ASSESSEMENT DISTRICT APPLIES

r ADMINISTRATIVE OFFICE

r DELIVERY VEHICLES

r RESIDENTIAL PROPERTY RENTALS

r COMMERCIAL PROPERTY RENTALS

DEPENDING UPON LOCATION)

r CONTRACTOR – STATE LICENSE NUMBER _________________________ CLASS _______________________

PLEASE PROVIDE AN ACCURATE DESCRIPTION OF PROPOSED BUSINESS OPERATION – BE SPECIFIC

RETAIL SALES TAX NUMBER

NUMBER OF SKILL/VIDEO GAMES

IF RESIDENTIAL/COMMERCIAL PROPERTY RENTAL BUSINESS, GIVE TOTAL NUMBER OF RENTAL UNITS.

LIST ADDRESS OF RENTAL UNITS BELOW. ATTACH AN ADDITIONAL SHEET IF NECESSARY.

1.

# OF UNITS

3.

# OF UNITS

2.

# OF UNITS

4.

# OF UNITS

TO COMPUTE LICENSE TAX, SEE ATTACHMENT. LIST GROSS EARNINGS, CURRENT TAX, APPLICATION FEE AND ASSESSMENT DISTRICT (IF APPLICABLE) IN BOXES BELOW.

ADD TOGETHER FOR TOTAL DUE.

LICENSE TAX

GROSS RECEIPTS

ASSESSMENT DISTRICT

APPLICATION FEE

PENALTY

TOTAL DUE

+

+

+

=

GROSS EARNINGS MUST BE VERIFIED BY TAX RETURN OR OTHER APPROPRIATE DOCUMENTATION.

I DECLARE UNDER PENALTIES OF PERJURY THAT THIS APPLICATION HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE,

CORRECT AND COMPLETE STATEMENT OF FACTS.

_________________________________________

_________________________________________

_____________________

SIGNATURE OF OWNER OR OFFICER

TITLE

DATE

_________________________________________

_________________________________________

_____________________

SIGNATURE OF OWNER OR OFFICER

TITLE

DATE

FOR OFFICE USE ONLY

OCCUPANCY PERMIT #