Application Form For Tax Or License Number - Jefferson County

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Department of Revenue
Complete and Return To:
Phone (205) 325-5180
(205) 325-5195
Jefferson County
Jefferson County, Alabama
Department of Revenue
Fax (205) 325-5695
(205) 214-8590
A-100 Courthouse Annex
716 Richard Arrington Jr. Blvd. N.
Birmingham, AL 35203
Application for Tax or License Number
For Office Use Only.
Reg. # ____________________________
Federal Employer Identification Number or Social Security Number:
Beginning Date of this Business in Jefferson County
(see instructions on back of application)
Month
Day
Year
Form of Organization:
Employees in Jefferson County:
4. Professional Association
Yes
No
1. Corporation
5. Other
Type of Business:
2. Partnership
6. Professional Corporation
1. Manufacturer
2. Contractor
3. Wholesaler
3. Sole Proprietorship
7. Limited Liability Corporation
4. Retailer
5. Other
Name of Proprietorship, Partnership, Corporation, or Association:
Trade Name if Different Than Name of Taxpayer:
Mailing Address to Which Tax Forms Are to be Sent:
Location Address of Office in Jefferson County:
(If more than 1, please list all locations on back of application. Do not use a P.O. Box.)
City
State
Zip
City
State
Zip
Contact Name:
Contact Name:
Phone Number:
Phone Number:
Fax Number:
Fax Number:
Email Address:
Email Address:
Is this a new business?
If no, name of former owner:
Principal Business Activity and Product : (example: Retail Sales/Apparel)
yes
no
Activity
Product
Please initial below and fill out the back of the
application if you want specific tax forms mailed to
Check the Taxes for Which
Begin Date of Tax Liability:
an address that is different from the mailing
You Are Liable:
Month
Day
Year
above
For office use only
F
Business License
Occupational Tax
Sales Tax
Seller's Use Tax
Consumer's Use Tax
Direct Pay (Formerly Regulation A)
Lodgings Tax
Tobacco tax (Wholesaler)
Cable TV Franchise Tax
* Wine Tax (Wholesaler)
* Beer Tax (Wholesaler)
* Alcoholic Beverage Tax (retailer)
* Motor Fuels Tax (distributor)
* These taxes require a bond to be posted with the Jefferson County Revenue Department. Call (205) 325-5181 for bond requirements.
I hereby certify that all information and statements herein are true and correct:
Please Print Name
Signature
Title
Date
For Office Use Only
Notes:
Privilege
Municipality: ____________________
Ordinance
NAICS Code: ___________________
Reviewed by: _____________________________________

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