Business License Questionnaire - City Of Jeffersontown Revenue Department
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CITY OF JEFFERSONTOWN
BUSINESS LICENSE QUESTIONNAIRE
Phone: (502) 267-8333
Fax: (502) 267-0547
Jeffersontown, Kentucky 40299
10416 Watterson Trail
Pursuant to City Ordinance No. 1127, Series 2007, persons, firms or organizations engaged in any trade or
profession operating in the City of Jeffersontown for profit or gain, to first register with said City.
COMPLETE
RETURN TO CITY HALL
Type or Print
PLEASE ANSWER ALL QUESTIONS
Type or Print
1. Name:
__________________________________________________________________
(If registering as individual)
2. Corporation Name: ____________________________________________________________________________
3. Trade Name or D.B.A.
________________________________________________________
(If different than above)
4. Primary Corporate/Business Address:
Street:____________________________________________________________ Phone: ___________________
City, State, Zip:_______________________________________________________ Fax: ____________________
Date Organized:________________ State or Country of Incorporation:___________________________________
5. Email Address: ________________________________ 6. Website: _____________________________________
7. Fed Tax I.D. or SS# :_______________________________ 8. If Non-Profit, Tax Exempt # ___________________
9. Nature of Business:____________________________________________________ 10. NAIC #______________
11. Date business or work started or will start in Jeffersontown: ___________ 12. Number of
employees: ______
IF BUSINESS EMPLOYS PEOPLE WORKING IN JEFFERSONTOWN, THEN EMPLOYER MUST FILE QUARTERLY
OCCUPATIONAL TAX RETURNS WITH THE CITY OF JEFFERSONTOWN.
13. If you are obtaining a previously established business or a change in the organization has occurred:
Date of change:________________________________ Date employment began:__________________________
Former corporate or trade name, if any:____________________________________________________________
(Please complete all applicable)
14. Addresses:
a. If business is physically located in Jeffersontown, Kentucky
Street:_________________________________________________ Zip:__________ Phone:_________________
Fax:_______________________________ Contact: _________________________________________________
b. Payroll Service address:
(If different than above)
Street:_______________________________________ City, State, Zip:__________________________________
Phone:_________________ Fax: _________________ Contact: _______________________________________
c. If corporation, LLC or LP, name and address of designated process agent in Kentucky.
Street:_______________________________________ City, State, Zip:__________________________________
Phone:_________________ Fax: _________________ Contact: _______________________________________
15. For additional information or in case of emergency contact:
Name:_________________________________________________ Phone: ______________________________
PLEASE NOTE
It is the applicant’s responsibility to inform the Revenue Department of any changes in
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ownership, addresses, number of employees or termination of business activity. The undersigned (business)
agrees to be responsible for all collection costs and attorney's fees in connection with any delinqent account.
Signature:_________________________________________________ Date: ________________________________
(FOR OFFICE USE ONLY)
Account Nos:______________________________________________________________________________________
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