Form Cof-11/09-Bar9 - Business License Application - City Of Fairfax
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1CITY OF FAIRFAX
WILLIAM
PAGE
JOHNSON, II
Commissioner of the Revenue
City Hall
,
Room 224"
10455
Annslrong Street"
Fairfax,
Virginia
22030
Phone
(703)
385-7880· FAX (703) 359-2499· e-mail: pjohnson@fairfaxva.gov
UCENSE NUMBER
FEDI!RAL I.D. OR SOCIAL SECURITY NO.
APPLICANTS
NAME _
_ _
__
_ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _
__
INDIVIDUAL
0
CORPORATION
0
TRADE NAM
E
(if
any)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__
__
_
PARTNERSHIP
0
ASSOCIATION
0
MAILING ADDRESS
BUS.
TEL.
NO.
_ _ _ _ _
__ __
CITY
/
STATE
/
ZIPCODE
_ _ _ _ _ _ _
__
__
_ _
__ _ _ _ _ _ _ _ _
BUS.FAXNO.
_ _ _
__ _ _
__
BUSINESS LOCATION
_ _ _ _ _ _ _ _ _ _ _ _ _ __
_______
_
_ _ _
E-MAIL
_ _ _ _
__
_
_
_
_ __
NATURE OF BUSINESS
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__ _ _ _ _ _
__ _ _ _ _ _ _ _
__ __
DO
YOU RENT OR
LEASE THESE BUSINESS
PREMISES?
0
YES
0
NO
NAME
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
____________
(IF
YES.
FURNISH
NAME AND ADDRESS OF LANDLORD OR LESSOR.)
...
MAILING ADDAESS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__
__
_
AMOUNTOFANNUAL
RENT
$
_ _ _ _ _ _ __
CITY
I
STATE
I
ZIP
CODE
_
_
_ _ _ _
__
__
_ _ _ _ _ _
__
[el; •
-
.
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~
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("'.I.".IM~I ·r.il
~
Enter
estimated
2010
Gr010S
Receipts
on Line
1 Column
A.
Enter rate
(lee
achedule) on Une
1
Column
B.
1
Multlply
Una 1 Column
A by
Una 1 Column
B and enter
,..utt
on Una 1
Column
C.
For
License
bated
on Flat
Rate
(see schedule)
entor on Line 2 Col
umn
c.
2
3
4
5
6
7
OATH:
I.
THE
UNDERSIGNED APPLICANT DO SWEAR (OR AFFIRM) THAT THE FOREGOING
FIGURES AND STATEMENTS ARE
TRUE.
FU
LL
AND
CORRECT
TO
THE
BEST
OF MY
SUBTOTAL:
KNOWLEDGE AND
BELIEF.
PENALTY:
INTEREST:
SIGNATURE
OF
APPUCANT
DAlE
TOTAL AMOUNT DUE:
PRINT
OR TYPE
NAAOE
AND TJTLE
OF PERSON
SIGNING
PI-!ONE
NUMBER
*
YOU MUST REPORT GROSS RECEIPTS
*
MAKE CHECK PAYABLE TO:
TREASURER,
CITY OF FAIRFAX
PLEASE REVIEW
REVERSE
SIDE
FOR
ADOmONAL INSTRUCTIONS
COF-11/09-BAr9
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Parent category: Business