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COMPLETE THIS APPLICATION IN FULL. PLEASE PRINT CLEARLY.

2002 APPLICATION FOR COUNTY OF FAIRFAX, BUSINESS, PROFESSIONAL AND OCCUPATIONAL LICENSE

D E P A R T M E N T O F T A X A D M I N I S T R A T I O N

1 2 0 0 0 G o v e r n m e n t C e n t e r P a r k w a y , S u i t e 2 2 3 , F a i r f a x , V i r g i n i a 2 2 0 3 5

P h o n e :

7 0 3 - - 2 2 2

7 0 3

2 2 2 - - 8 2 3 4

8 2 3 4

F a x :

7 0 3 - - 3 2 4

7 0 3

3 2 4 - - 3 5 0 0

3 5 0 0

T T Y :

( 7 0 3 ) 2 2 2 - - 7 5 9 4 W e b S i t e :

( 7 0 3 ) 2 2 2

7 5 9 4 W e b S i t e :

w w w . c o . f a i r f a x . v a . u s / d t a

9. Business Contact/Title:

1. Owner Name:

Phone Number:

Fax Number:

2. Trade Name:

E-mail:

3. Federal ID/SSN:

10. Description of Business:

4. Date Business Began in Fairfax County:

5. Date Business Ended in Fairfax County:

If Business Operates from Leased Premises

6. Current Business Location:

11. Annual Rent Paid: $

11a. Name/Address of Owner of Premises:

7. Mailing Address:

8. Number of Persons Employed at this location: ______________

BOX 1

BOX 2

BOX 3

BOX 4

NOTE: It is a Class I misdemeanor for any person to willfully subscribe an application

ALL BUSINESSES, EXCEPT RESEARCH & DEVELOPMENT, COMPLETE BOXES 1 THROUGH 4

that he does not believe to be true and correct as to every material matter, Virginia Code

Section 58.1-11. Businesses are subject to audit by DTA pursuant to Virginia Code

Total 2001

Exclusions

Adjusted 2001

If business began after 1-1-01

Section 58.1-3109.

*Gross Receipts

(See Back of Form)

Gross Receipts

report gross receipts

Declaration: I declare that the statements and figures herein given are true, full and cor-

(Box 1 less Box 2)

estimate for 2002

rect to the best of my knowledge and belief.

Print Name/Title:

RESEARCH & DEVELOPMENT BUSINESSES ONLY, COMPLETE BOXES 5 THROUGH 8

Signature:

Phone:

Fax Number:

BOX 5

BOX 6

BOX 7

BOX 8

E-mail:

If business began after

Total 2001

Non-Federal Appropriations

Federal Appropriations

1-1-01 report gross receipts

Date:

Gross Receipts

(See Back of Form)

(Box 5 less Box 6)

estimate for 2002

Account Number

Ordinance

SIC

Check boxes that apply: (see GENERAL section of instructions on the back of this form)

♦

Software developers deducting receipts as allowed by Chapter 4-7.1-1-B(1)-(z) Fairfax County Code ONLY – check __

♦

Reviewed by

Date Received

Seller of Computer Hardware/Software to Federal or State Government Entity as allowed by Code of Virginia, Title 58.1.3732 , ONLY – check __

∗

Wholesale Merchants Only: Report gross purchases.

8TA-E1

OFFICE USE ONLY

Form 8ta-E1 - Application For County Of Fairfax, Business, Professional And Occupational License - 2002

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