Application For License, Transaction Privilege (Sales) And Use Tax - City Of Mesa

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Licensing Office
Mailing Address
55 North Center Street
PO Box 1466
Mesa Arizona 85201
Mesa Arizona 85211-1466
(480) 644-2316
(480)644-3999 Fax
APPLICATION FOR LICENSE, TRANSACTION PRIVILEGE (SALES) AND USE TAX
NON-REFUNDABLE $50.00 DUE AT THE TIME OF APPLICATION
Office Use Only
New Business
Former Owner (if applicable)
Forner Owner's License #
Check one:
License #
New Owner of Existing Business
Name Change Only
Current City License # (if name change only)
SIC Code
SECTION I. BUSINESS INFORMATION
Dist. Code
Business Nam e (Individual, Com pany or "DBA", first nam e first)
Initials
Street No.
(N,E,S,W )
Street Nam e
Type
Ste/Apt #
-
-
City
State
ZIP Code + 4
Area Code
Business Telephone #
Zoning
Start Date in Mesa
E-mail address
-
Approved
State License #
Federal ID #
SECTION II. MAILING ADDRESS & PHONE NUMBER
Denied
Enter Nam e if Different from Section I (above) or Enter 'In-Care-Of' Nam e
Comments
Street No.
(N,E,S,W )
Street Nam e
Type
Ste/Apt #
-
City
State
ZIP Code
Area Code
Telephone #
SECTION III. BUSINESS OWNERSHIP & RECORD LOCATION
Ownership:
Individual
LLC
Corp. - State Inc.______
Gen. Partnership
Ltd. Partnership
Other _____________
1)
Name
Title
Owners, Partners,
LLC Members, or
Home Address
Social Security #
For Additional
Officers
Locations in
(For Additional Names,
City
State
ZIP Code
Phone No.
Please Attach List)
Mesa
(
)
Consolidate with
2)
Name
Title
Mesa License #
Home Address
Social Security #
City
State
ZIP Code
Phone No.
(
)
Corporate or LLC
Name
Phone No.
(
)
Statutory Agent
Name
Phone No.
Location Where
(
)
Business Records
Address
City
State
ZIP Code
Are Kept
Section IV. Business Type
Retail Sales
Wholesaler
Amusement
Construction Contracting
Use Tax
Restaurant/Bar
Business Type
Manufacturer
Commercial Rental
Residential Rental (# of Units ______ )
Hotel/Motel
Other______________
Describe Nature of
Contractors #
Business
# of Employees
Check method you will use in submitting reports:
Cash Receipts
Accrual
Section V. Business Premises Status
Check one:
Do you own your business location?
Yes
No
If yes, Is this your residence?
Yes
No
If no, complete Landlord/Property Manager information
Landlord/Property Manager Name
Address
Phone #
(
)
Do you rent a portion of the business premises to another entity?
Yes
No
I certify that the statements made in this application are true and complete to the best of my knowledge. I accept the license authorized and issued in
response to this application with the condition that I report timely and pay any and all taxes due by me to the city. Incomplete forms may not be processed.
IF APPLICABLE, BE SURE ALL SALES TAX HAS BEEN PAID BY FORMER OWNER. BY LAW YOU MAY BE LIABLE FOR ANY UNPAID TAX.
P rin t N a m e
S ig n a tu re
T itle
D a te
For office use only

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