Application For County License-Other Than Bpol

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APPLICATION FOR COUNTY LICENSE-OTHER THAN BPOL
Return all copies with check made payable to County of Fairfax
Department of Tax Administration, 12000 Government Center Pkwy., Suite 223 Fairfax, Va. 22035-0029
Name of Business & Mailing Address:
LICENSE YEAR
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
23-1-2
Bondsman
1/1-12/31
000018
0433
N/A
25-1-1
Carnival/
N/A
000018
0434
N/A
Circuses
27-1-4
Dance Hall
1/1-12/31
000018
0435
N/A
4-12-1
Fortune
1/1-12/31
000018
0436
N/A
Teller
4-9-1
Mixed Bev
1/1-12/31
000018
0437
Seating
Capacity
109-4-4
Refuse
7/1-6/30
450201
0441
Permit # by
Truck
Truck
TOTALS…………………………………………………………………………..
SIGNATURE OF APPLICANT
DATE
LOCATION OF BUSINESS:
PHONE#
For Office Use Only
Business Processing & Information….Processed By:
Revenue Collection…..Processed By
Copies
White – Business Processing & Information
Yellow -- Applicant
Pink - Revenue Collection

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