Application For Temporary Philadelphia Business Privilege License Form printable pdf download

CITY OF PHILADELPHIA

Revenue Code 3710

APPLICATION FOR

DEPARTMENT OF LICENSES AND INSPECTIONS

TEMPORARY PHILADELPHIA

CONCOURSE LEVEL

BUSINESS PRIVILEGE LICENSE

1401 JOHN F. KENNEDY BOULEVARD

Fee $100.00

PHILADELPHIA, PA 19102

READ INSTRUCTIONS BELOW BEFORE COMPLETING THIS FORM . CLEARLY PRINT OR TYPE ALL INFORMATION.

FEDERAL EMPLOYER IDENTIFICATION NUMBER

SOCIAL SECURITY NUMBER

PA. STATE SALES TAX NUMBER

EVENT DATES:

EVENT:

EVENT LOCATION:

1. APPLICANT NAME

1A. TRADE NAME (IF APPLICABLE)

2. BUSINESS ADDRESS (NUMBER AND STREET. DO NOT USE P.O. BOX NUMBERS.)

CITY

STATE

ZIP CODE

3. MAILING ADDRESS IF DIFFERENT FROM ABOVE

CITY

STATE

ZIP CODE

4. BRANCH OFFICE ADDRESS (IF ANY)

CITY

STATE

ZIP CODE

5. BUSINESS PHONE NUMBER

6. HOME PHONE NUMBER

7. FAX NUMBER

8. E-MAIL ADDRESS

9. INDIVIDUALS, PARTNERS OR OFFICERS NAMES

10. HOME ADDRESS

11. SOCIAL SECURITY NUMBER

I understand that if I knowingly make any false statement herein, I am subject to such penalties as may be prescribed by law.

____________________________

______________________

_____________

_________

SIGNATURE

PRINT NAME

TITLE

DATE

Department of Licenses and Inspections information:

PHONE: 215-686-2490 or 215-686-5153

E-MAIL: license.issuance@phila.gov

INTERNET: phila.gov/li

INSTRUCTIONS - READ CAREFULLY

Your Federal Employer Identification Number must be entered on this application.

A Social Security Number must be entered for a Sole Proprietorship.

You must enter the Pennsylvania Sales and Use Tax license number or Sales and Use Tax exemption number.

1. NAME OF TAXPAYER(S) OR TAX ENTITY - If a corporation, use exact legal corporate name. If a partnership, use name of partners.

If an individual proprietorship, use name of owner (last name first, first name and middle initial). The entity name is the name in which

your account will be filed and the name printed on all tax returns mailed to you.

1A. TRADE NAME - If you operate your business under a different name than in block 1, enter here.

2. BUSINESS ADDRESS - Enter primary business location.

3. MAILING ADDRESS - If different than business address, enter here.

4. BRANCH OFFICE ADDRESSES - Enter only Philadelphia branch offices.

5, 6, 7 & 8 - Self explanatory.

9, 10 & 11 - INDIVIDUAL'S PARTNERS' OR OFFICERS' NAMES; ADDRESSES AND SOCIAL SECURITY NUMBER - This information is

also considered a vital portion of your tax record and must be included on this form in full detail for all partners, corporate officers and/or

individual owners.

This License valid only for the date(s) listed above.

Application For Temporary Philadelphia Business Privilege License Form

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