Occupational Tax Regulatory Fee Registration Form

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TOWN OF BETHLEHEM OCCUPATIONAL TAX
REGULATORY FEE
REGISTRATION FORM
Name of Business_________________________________
Date: _______________
Location of Business:
Mailing address of business (if different):
Street: __________________________
Street or P.O.________________________
City: ____________________________
City: _______________________________
State/zip code_____________________
State/zip code________________________
nd
Daytime phone: ________________
2
line: ____________
Pager/cell: ______________
Social security no. /Federal ID: _________________________
Sales tax
no.:______________
Business activity: _____________________________________________________________________
Owner/registered agent:
President/partner:
Name: _____________________________
Name: __________________________________
Street/P.O.:____________________________
Street/P.O.:____________________________
City/State/zip: __________________________
City/State/zip: __________________________
Phone: __________________________
Phone: __________________________
On a monthly average how many full-time employees do you have? ___________________________
On a monthly average how many part-time employees do you have? ___________________________
Print name: _____________________________
Signature: ______________________________
(Tax assessor)
(Planning & zoning)
Current Zoning
Date: _________
Date: ___________
_____________
Map: _________
Map: ___________
Parcel: __________
Parcel: ____________
District: _________
Start Date: _________
Checked by: __________
Checked by: __________
Is location approved for this business? __________________________________________________
Tax liability per number of employees
0-3
$25.00
4 or more
$25.00 plus $5.00 per employee over three
There is a maximum tax liability of $1,000 per business.
OCCUPATIONAL TAX NUMBER_______________
Town of Bethlehem
P.O. Box 210
750 Manger Ave.
Bethlehem, GA. 30620
(770) 867-0702

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