Application For Portland Business License Form - 2003
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City of Portland Oregon
Bureau of Licenses
OFFICE USE ONLY
111 SW Columbia, Suite 600
REVISED 1/03
Portland OR 97201-5814
ACCOUNT #
Office: (503) 823-5157
FAX: (503) 823-5189
Web: www pdxbl org
APPLICATION FOR PORTLAND BUSINESS LICENSE
M
$100.00 N
-R
Checks payable to: CITY OF PORTLAND
INIMUM FEE IS
ON
EFUNDABLE
SOME OF THE INFORMATION PROVIDED ON THIS FORM MAY BE SUBJECT TO DISCLOSURE UNDER PUBLIC RECORD LAW
1)
NAME:
PRINT Name(s) of Owners, Partners, Corporation – as filed on the State of Oregon Tax Return
OWNERS
ALL PARTNERS
OWNERS: PLEASE LIST
OF CORPORATIONS (OWN 5% STOCK) &
ON THE BACK OF THIS FORM.
2)
BUSINESS NAME/Doing Business As (DBA): [If different from above NAME]
3) BUSINESS CODE (NAICS - see
instructions)
4)
BUSINESS CONTACT NAME:
CONTACT TITLE:
CONTACT PHONE:
(
)
Is this person authorized to represent the licensee?
Yes
No
5)
TAX ENTITY:
Sole Proprietor/1 Mbr LLC
Partnership
Corporation
Estate
Trust
Ltd. Liability Company
Ltd. Partnership
S – Corporation
Other:
(check one)
6)
FISCAL YEAR
BUSINESS FAX:
7)
TAX ENTITY ID # (Not subject to disclosure)
END:
(
)
F.E.I.N:
SS #:
8)
NUMBER OF
9)
DATE BUSINESS ACTIVITY
?
10) Is business activity performed outside Portland
Yes
No
OWNERS:
BEGAN IN PORTLAND:
(MM/DD/YY)
?
11) Is this a new business
Yes
No
IF business previously licensed, name of previous owner:
12) Email Address:
13)
PRIMARY BUSINESS ADDRESS: (location)
(List additional locations in space provided below)
Number/Street - NOT PO BOX
City, State, Zip Code
14) BUSINESS ACTIVITY DESCRIPTION:
15) BUSINESS
CODE
(NAICS)
If business activity includes rental/leasing residential or commercial property, list property addresses on back of this form
17)
PROPERTY TYPE: Is business address on:
16)
BUSINESS PHONE:
COMMERCIAL
RESIDENTIAL property?
(
)
18) MAILING ADDRESS:
(If different from line 13 above)
19) LIST ADDITIONAL BUSINESS ADDRESSES, BUSINESS NAME, & BUSINESS CODE (NAICS) AT EACH LOCATION.
Use additional sheets if necessary
LOC
BUSINESS
LOCATION ADDRESS
BUSINESS NAME AT THIS LOCATION
#
CODE/NAICS
For office use only
:
$
PAYMENT:
CASH
RECEIPT #
CHECK #:
PDX: Total $_________ Status: _____ TO: _________________ Comment:
MULT: Total $_________ Status: ______ TO: _________________ Comment:
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