Business Certificate Worksheet Form Page 2
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3BUSINESS CERTIFICATE WORKSHEET FORM
C I T Y
O F
S P R I N G F I E L D
NEW ____ RENEWAL ____ DISCONTINUANCE ___(Check One)
IN CONFORMITY WITH THE PROVISIONS OF CHAPTER 110, SECTION 5 OF THE GENERAL LAW, AS AMENDED,
THE UNDERSIGNED HEREBY DECLARE THAT A BUSINESS IS CONDUCTED UNDER THE NAME OF:
__________________________________________________________________________________
AT
___________________________________________________________________________________
(
ADDRESS)
IS THE ABOVE ADDRESS THE PROPER MAILING ADDRESS FOR ALL PUBLIC CORRESPONDENCE: YES _____
NO ______. IF NOT, PLEASE PROVIDE MAILING ADDRESS BELOW.
OR
SOCIAL SECURITY # _______/______/_________
FEDERAL ID # _______/_______________________
BUSINESS TELEPHONE NUMBER ______/_____________________
HOME # ______/____________________
BUSINESS FAX NUMBER ______/_________________ E-MAIL ADDRESS_____________________________________
TYPE OF BUSINESS: _________________________________________________
PARENT CORPORATION IF ANY: ______________________________________________________________________
ADDRESS: ____________________________________________________________________________________________
NUMBER OF EMPLOYEES: _______ (PROOF OF STATE WORKER’S COMPENSATION INSURANCE IS REQUIRED
IF YOU HAVE EMPLOYEES, THE CITY WILL NOT ACCEPT AN APPLICATION WITHOUT PROOF OF WORKER’S
COMPENSATION INSURANCE)
BY THE FOLLOWING NAMED PERSON(S):
FULL NAME
RESIDENT ADDRESS
(First/Middle/Last/Title)
(No./Street/City/State/Zip)
_______________________________________________
______________________________________________________
_______________________________________________
______________________________________________________
_______________________________________________
______________________________________________________
MAILING ADDRESS
___________/________________________________________________________
NUMBER
STREET
___________________________________________/_______/________________
CITY
STATE
ZIP
SIGNATURE(S):
___________________________________________________
___________________________________________________
___________________________________________________
FOR CITY USE ONLY: Send Copy to Board of Assessors
OVER
REVISED 11/10
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