Application For County License-Other Than Bpol Form - 2010

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County of Fairfax
Department of Tax Administration (DTA)
12000 Government Center Parkway, Suite 261
Fairfax, Virginia 22035
Phone: 703-222-8234 FAX: 703-324-3500
Application for County License – Other than BPOL
License Year
Name of Business and Mailing Address
Name of Business and Mailing Address:
Account #
LICENSE YEAR
Date Business Began
ACCOUNT #
DATE BUSINESS BEGAN
Ord.
License
License
Index
Sub
Info
Section
Type
Period
Code
Code
Req
Tax
Penalty
Total
21-1-2
Auto
1/1-12/31
000018
0432
N/A
Graveyard
Renewal due
Jan. 31
23-1-2
Bondsman
1/1-12/31
000018
0433
N/A
Renewal due
Jan. 31
25-1-1
Carnival/
N/A
000018
0434
N/A
Circus
27-1-4
Dance Hall
1/1-12/31
000018
0435
N/A
Renewal due
January 31
4-12-1
Fortune
1/1-12/31
000018
0436
N/A
Teller
Renewal due
Jan. 31
4-9-1
Mixed Bev
1/1-12/31
000018
0437
Seating Capacity
Renewal due
Jan. 31
TOTALS
Location of Business
SIGNATURE OF APPLICANT
DATE
Phone
LOCATION OF BUSINESS:
E-Mail
Signature
Date
Name and Title
PHONE#
FOR OFFICE USE ONLY
(FOR OFFICE USE ONLY)
BUSINESS PROCESSING and INFORMATION… PROCESSED BY:
BUSINESS PROCESSING AND INFORMATION… PROCESSED BY:
REVENUE COLLECTION… PROCESSED BY
REVENUE COLLECTION… PROCESSED BY
Copies
Copies: White - DTA
White - DTA
September 2010
Retain Yellow Copy For Your Records
Retain Yellow Copy For Your Records

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