Application For Business License Exemption Form
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1Randy Leonard, Commissioner
OFFICE USE ONLY:
Thomas Lannom, Interim Director
111 SW Columbia, Suite 600
ACCOUNT #:
Portland, OR 97201-5814
DATE ACCEPTED:
(503) 823-5157
Fax: (503) 823-5192
INITIAL:
TDD: (503) 823-6868
Web:
APPLICATION FOR BUSINESS LICENSE EXEMPTION
1)
NAME:
PRINT Name(s) of Owners, Partners, Corporation – as filed on the State of Oregon Tax Return
2)
BUSINESS NAME/Doing Business As (DBA):
If different from above NAME
3)
BUSINESS CONTACT NAME:
CONTACT TITLE:
CONTACT PHONE:
(
)
Is this person authorized to represent the licensee?
Yes
No
4)
TAX ENTITY:
Sole Proprietor
Partnership
Corporation
Estate
Trust
Ltd. Liability Co.
Ltd. Partnership
S – Corporation
Other:
(check one)
5)
FISCAL YEAR
BUSINESS FAX:
6)
TAX ENTITY ID # (not subject to disclosure)
END:
(
)
F.E.I.N:
SS #:
7)
NUMBER OF
8)
DATE BUSINESS ACTIVITY
?
9)
Is this business activity outside Portland
Yes
No
OWNERS:
BEGAN IN PORTLAND:
IF YES, describe business activity outside Portland:
10) BUSINESS ADDRESS: (location)
Number/Street NOT PO BOX
City, State, Zip Code
11) BUSINESS PHONE:
12)
PROPERTY TYPE: Is business address on:
(
)
COMMERCIAL
RESIDENTIAL property?
13) BUSINESS ACTIVITY DESCRIPTION:
(office use only)
SIC
CODE:
14) MAILING ADDRESS:
(If different from line 10 above)
15) Is this a new business?
Yes
No
IF business was previously licensed, give name of previous owner:
16) If any of the current owners of this business have a current or expired PORTLAND license, give account information:
NAME:
ACCOUNT #:
YEAR LICENSED:
_
IN ORDER TO OBTAIN AN EXEMPTION FOR AN EXISTING LICENSE OR TO OBTAIN AN EXEMPTION FOR A SECOND YEAR
IT IS NECESSARY TO PROVIDE COPIES OF APPLICABLE TAX RETURNS.
EXEMPTION BY REASON OF GROSS INCOME (RECEIPTS)
I hereby state that the EXPECTED gross income (receipts) from all activity everywhere of this business will be less than $25,000 for
the calendar/fiscal year
. By Business Law, Title 7.02.400, this business is therefore exempt from the
licensing required for the above stated year. I understand that should the gross receipts exceed $25,000 for that year, the exemption
will no longer be in effect and I will be under obligation to immediately obtain a license for that year, even if that year has passed. I
further understand that failure to obtain a business license when required to do so will subject me to penalties.
S
IGNATURE
DATE
NO LICENSE WILL BE ISSUED
KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Some of the information provided on this form may be subject to disclosure under public record law
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