Application For Business Tax Registration Certificate Form - Sole Proprietorship - Office Of The Treasurer/tax Collector

OFFICE OF THE TREASURER/TAX COLLECTOR

CERTIFICATE NO:_________________

JOSÉ CISNEROS, Treasurer

GEORGE PUTRIS, Tax Administrator

Registration Fee:__________________________

Initials & Date:____________________________

Office Use Only

A P P L I C A T I O N

BUSINESS TAX REGISTRATION CERTIFICATE

SOLE PROPRIETORSHIP

Please Print or Type

OWNERSHIP NAME:________________________________________

________________________________________

_____________

Last Name

First Name

Middle Initial

__________ - __________ - _________

_______________________

OWNERSHIP TYPE:

Individual

Trust Estate Other

Social Security Number

S.F. Starting Date

Complete Part A, if the residence address is different from the mailing address.

MAILING ADDRESS

AND

Complete Part B, if the accounting record location is different from the mailing address.

Complete all Information

Complete Part C, if the business location is different from the mailing address.

____________________________________

____________________________________

____________

______________________________________

Last Name

First Name

Middle Initial

Title/Position

____________________________________________________________________________

(

)_________________

Street Address

Telephone

____________________________________

____________________________________

____________

______________________________________

City

State

Zip Code

Country (Foreign Address)

PART A: RESIDENCE ADDRESS

____________________________________

_____________________________________

____________

____________________________________

Last Name

First Name

Middle Initial

Title/Position

_____________________________________________________________________________

(

_)________________

Street Address

Telephone

____________________________________

_____________________________________

___________

_____________________________________

City

State

Zip Code

Country (Foreign Address)

PART B: ACCOUNTING RECORD LOCATION

____________________________________

_____________________________________

____________

_____________________________________

Last Name

First Name

Middle Initial

Title/Position

_____________________________________________________________________________

(

)_________________

Street Address

Telephone

____________________________________

_____________________________________

___________

_____________________________________

City

State

Zip Code

Country (Foreign Address)

PART C: BUSINESS LOCATION

____________ ___________________________________________ ___________ ________________________ ____________ (

_ )________________

Street No.

Street Name (P.O. Box Not Acceptable)

Suite/Room

City, State

Zip Code

Telephone

BUSINESS NAME (DBA):______________________________________________________________________________________________________________

(30 Characters Maximum)

BUSINESS DESCRIPTION:

__________________________________________________________

$___________________________ ____________

_____________

____________

Description of Business

Est. Payroll (12 mos)

# Employees

Business Class

PBC

__________________________________________________________

$___________________________ ____________

_____________

____________

Description of Business

Est. Payroll (12 mos)

# Employees

Business Class

PBC

FOR APARTMENT BUILDING OWNER/OPERATOR - No. of Apt. Units:___________________

No. of Commercial Units:__________________

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I declare under penalty of perjury that I have examined this application and that the information contained herein is true and complete to the best of my knowledge

and belief. I understand that misrepresentation of information is subject to a penalty of up to $500. (Municipal Code, Part III, Sec. 6.17-3)

SIGNATURE:_________________________________________________________

_____________________________________________________

Applicant's Name

Print Name

DATE:_______________________________________________________________

TELEPHONE: (

)_______________________________

Instructions are on the reverse side

Sole Proprietorship (rev. 8/04))