Business, Professional And Occupational License Application - 2015

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2015
COUNTY OF FAIRFAX
BUSINESS, PROFESSIONAL AND OCCUPATIONAL LICENSE APPLICATION
DEPARTMENT OF TAX ADMINISTRATION
12000 Government Center Parkway, Suite 223, Fairfax, Virginia 22035
Phone: 703-222—8234 Fax: 703-324—3500 or 703-324-3505 TTY: 703-222—7594 Online:
1. Owner Name:*
* Sole Proprietors Use:
Last Name
2. Trade Name:
3. Federal ID/SSN:
4. Date Business Began in Fairfax Countyy
5. Date Business Ended in Fairfax County:
6. Current Business Location:
8. Number of Employees at This Location:
9. Business Contact:
Phone Number:
E-mail:
Fax Number:
10. If Business Operates from Leased Premises:
(a). Annual Rent Paid: $
(b). Name/Address/Phone Number of Owner of Premises:
7. Mailing Address (if different from location):
in completing Boxes 1 through 4 below, all businesses except wholesale merchants must report gross receipts. Wholesale
merchants may report gross purchases in lieu of receipts, if available.
Declaration: I declare that the statements and figures herein given are true, full, and correct
to the best of my knowledge and belief.
Print Name/Title:
Signature:
E-mail:
Date:
PLEASE PRINT CLEARLY AND SEE REVERSE SIDE FOR INSTRUCTIONS.
11. Provide a detailed description of business activity conducted in Fairfax County:
12. NAICS Code:
13. Contractors, Builders & Developers, Architects and Engineers:
State License #:
Expiration Date:
14.
Required For Retail Merchants Only:
Sales Tax Locality Code:
Account Number
OFFICE USE ONLY
Ordinance
NAICS
Reviewed by
3
Date Received
8TA-E1
Nov. 2014
0

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