Occupational License Application Form
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1
2Campbell County & Cities Occupational License Application
O
U
O
1209
FFICIAL
SE
NLY GAL
Campbell County Fiscal Court
Occ License Office
1098 Monmouth St. Rm. 320
Newport, KY 41071
A
ID # _________________
CCOUNT
Mailing Address: P O Box 72958
Newport, KY 41072-0958
C3 20___ ____
C2 20___ ___
NEW
Phone: (859) 292-3884 Fax: (859) 292-3827 website:
SLISCODE#___________________
INITIAL ______DATE __________
IMPORTANT! ZONING OR OTHER PERMIT MAY BE REQUIRED BEFORE YOU BEGIN BUSINESS
ACTIVITY. CONTACT CITY OR COUNTY ON REVERSE AS NEEDED FOR DETERMINATION.
1. Check one______ New application ______ Adding a city license to account #_______________
2. Check below any city where business is conducted:
Make check payable to “Campbell County Fiscal Court”
Total $ _____________
_X_$25 Campbell Co
___$75 Alexandria
___$25 Cold Spring ___$25 Fort Thomas
___$75 Highland Heights
___$50 Melbourne
___$35 Southgate
___$50 Woodlawn
Every business or individual subject to the Campbell County Occupational License Ordinance is required to complete this application and return it to the Campbell
County Fiscal Court Occupational License Inspector.
According to an opinion (OAG 85-1) of the Kentucky Attorney General, the responses that you make to
questions 4, 5, 6 and 7 below are to be provided to anyone upon request, pursuant to “Kentucky Open Records Law.”
WARNING: Statements in this
application shall be made under oath, or by affirmation or by any other legally authorized manner of attesting to the truth of such statement. Any false statements
made herein shall be punishable according to law.
READ CAREFULLY
3. Check One:
Individual / Sole Proprietorship
INSTRUCTIONS ON REVERSE
LLP / Partnership (attach a list of general partners names, home addresses & SSN)
TYPE OR PRINT LEGIBLY
LLC (attach a list of managers and/or members, home addresses &SSN)
Corporation (attach a list of officers names, home addresses & SSN) Date organized _____State ____
Not- for-Profit (attach IRS determination of status)
4. Legal business name: _____________________________________________________________________________________________________
5. Trade Name or DBA (if other than #3 above):
_________________________________________________________________________________
6. Brief description of business activity: ________________________________________________________________________________________
7. Primary Business Address or Corporate Headquarters:
8. Campbell County, Kentucky Business Locations (Record other
No P.O. Box
locations on reverse side):
No P.O. Box
Contact Name ___________________________________________
Contact Name ___________________________________________
Address________________________________________________
Address________________________________________________
________________________________________________
________________________________________________
City
_________________________State____ Zipcode ________
City
_________________________State____ Zipcode ________
Telephone (
) _________________________
Telephone (
) _________________________
9. Mailing Address for Quarterly Payroll Withholding Forms
10. Mailing Address for Annual Return or Home Address for
(Employers Only):
Individual/Sole:
Contact Name ___________________________________________
Contact Name ___________________________________________
Address________________________________________________
Address________________________________________________
________________________________________________
________________________________________________
City
_________________________State____ Zipcode ________
City
_________________________State____ Zipcode ________
Telephone (
) _________________________
Telephone (
) _________________________
11. Federal ID No.
AND Social Security No.
(Individual/Sole)
12. If Individual, S-Corp., or Partnership, your year-end is 12/31. Corporations give year-end month:
13. When did or will you start operating a business in Campbell County, (whether inside or outside a city)? Mo
Day
Yr
14. When did or will you first pay employees for working in Campbell County and Cities? Mo
Day
Yr
I have no employees.
15. Do you or will you use “leased” employees? Yes
No
If yes, include name, address and phone of leasing agency: ___________________
16. Do you or will you use independent contractors? Yes
No
If yes, attach list with name, address and phone number of contractors ___________
17. If business was obtained from a previous owner, or a change in the type of organization has occurred:
Give date of acquisition or change. Date ____________________________
Give name of previous owner or organization. ____________________________________
Give former trade name, if any _________________________________________________
18. Will any part of business activities be performed from your home? Yes
No
HO WndwCust
Chk#
I hereby certify that I am duly authorized to act for the applicant and the statements contained herein are
19. SIGNATURE:
true and complete. Verification will be issued upon processing completed application.
If individual sign your name:
X___________________________________________________________________
If partnership signature of general partner:
If corporation signature of corporate officer and title:
Printed Name: ____________________________________________________Title: ____________________________ Date: _________________
(For LLC, LLP & Corporations: List ON REVERSE the Names, Addresses and Social Security Numbers of Officers /Partners OR attach separate sheet)
CONTINUE ON REVERSE
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