Application For Spotsylvania County Business, Professional & Occupational License

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APPLICATION FOR SPOTSYLVANIA COUNTY
Tax Year ______
BUSINESS, PROFESSIONAL & OCCUPATIONAL LICENSE
COMMISSIONER OF THE REVENUE
DEBORAH F WILLIAMS
Business License # _________
P O BOX 175
SPOTSYLVANIA, VA 22553
Phone: (540) 507-7051
SECTION A – Owner & Business Information
1.
Owner’s Name:
________________________________________________________________________________________________
(If a Corp, S Corp, LLC, etc then please give the name as filed with the State of Virginia)
2.
Mailing Address:
_____________________________________________________________________________________________
PO Box or Block/Street Name
City
State
Zip
3.
Social Security #
Social Security #
Fed Employer Id #
______-_____-_____
_____-_____-_____
______-________________
4.
Trade Name:
___________________________________________________________________________________________________
5.
Physical Address:
______________________________________________________________________________________________
Block/ Street Name (No PO Boxes)
City
State
Zip
If the physical address is located in Spotsylvania County, please provide a copy of an approved
zoning and a copy of the registered name certificate filed with the Clerk of the Circuit Court.
(
) ____-______ ext ____
(
) ____-_______ ext _____
6.
Owner’s Phone
Business Phone
SECTION B – Type of
Business:
Sole Proprietor
Partnership
Corporation
Other
If Va Corp, give date of charter: ____ / ____ / ____
If foreign corp, give date of qualification in Va: ____ / ____ / _____
Registered Agent’s Name: ______________________________________________________________________________
Mailing Address: ______________________________________________________________________________
P O Box or Block/Street Name
City
State
Zip
:____________________________________________________
SECTION C – Description of Business
____________________________________________________
SECTION D – Contractors
SECTION E – Retail Merchants
Va State Contractors License # ______-_________
Va State Sales Tax Registration #__________________
SECTION F – # of Employees
______
SECTION G – Type of accounting
Cash
Accrual
SECTION H – Start Date :
_____/____/____
Mnth
Day
Yr
Gross Receipts
1. Please estimate the gross receipts if the business started in the current year.
----->
$
.00
OR
2. If the start date is prior to _____, please give actual gross receipts for the last year ----->
$
.00
and estimate for ______.
----->
$
.00
SECTION I – Declaration
FOR OFFICE USE ONLY
I, the undersigned, hereby certified under penalty of
perjury, that the information provided herein and
BPOL CODE _____
SIC _____ WCC ___
above, is true and correct to the best of my/our
ZONING # ________________
knowledge and belief.
________________________
Net Tax
$ ___________
_______________________________ __________
Signature of Applicant for License
Date
LF Penalty $___________
_______________________________ __________
Total Tax
$___________
or Authorized Agent
Date
Posted _____/_____/_____ by _______

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