Transaction Privilege (Sales) And Use Tax Application - City Of Mesa Revenue Collections Operations - 2009
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1
2
3Revenue Collections Operations
Mailing Address
Licensing Office
PO Box 1466
55 North Center Street
Mesa Arizona 85211-1466
Mesa Arizona 85201
(480)644-3999 Fax
(480) 644-2316
TRANSACTION PRIVILEGE (SALES) & USE TAX APPLICATION
LATE FEES APPLICABLE IF NOT LICENSED ON BUSINESS START DATE - NON-REFUNDABLE LICENSING FEE -
$50 FOR BUSINESS START DATES PRIOR TO 12/31/08 AND $30 FOR BUSINESS START DATES AFTER 1/1/2009
Start Date of taxable activity in Mesa (REQUIRED)
Incomplete forms may not be processed.
See reverse side for instructions.
SECTION I: TYPE OF APPLICATION
Former Owner Name (if applicable)
New Business/Entity Change
Check one:
New Owner of Existing Business
Current City License #
Date of Change (required for Bus or Loc change)
Business Name Change
Location Change
SECTION II. BUSINESS INFORMATION
Business Name: Company, "DBA" or Individual (first, mi, last)
Location Address: (actual street address of the commercial rental property, retail store, restaurant, etc. NOT A PO BOX NUMBER OR POSTAL MAIL BOX)
City
State
Zip
Business Phone Number (including area code)
Corporate or LLC Name (if different from business name)
Corporate Phone Number (including area code)
Corporate or LLC Address (Street, City, State, Zip)
State License #
Federal ID #
E-mail address
Website Address
SECTION III. MAILING ADDRESS
Office Use Only
Mailing Name
License #
Mailing Address
City
State
Zip
Phone Number (including area code)
SIC Code
SECTION IV. BUSINESS OWNERSHIP & RECORD LOCATION
Zoning
Zoning
O
Ownership:
Other _______
Other _______
Individual
Individual
LLC
LLC
Corporation - State ______
Corporation - State ______
Partnership
Partnership
Ltd. Partnership
Ltd. Partnership
Name
Title
Owners, Partners,
LLC Members, or
Home Address
Social Security #
Initials
Officers
(For Additional Names,
City
State
ZIP Code
Phone No.
Please Attach List)
(
)
Name
Title
For Multiple
Home Address
Social Security #
Locations in Mesa
City
State
ZIP Code
Phone No.
Consolidate with Mesa
(
)
Master License #
Name
Phone No.
Corporate or LLC
(
)
Statutory Agent
Name
Phone No.
Location Where
(
)
Business Records
Address
City
State
ZIP Code
Are Kept
Section V. Business Type
Internet/online Sales
Business Type
Const/Contracting
Restaurant/Bar
Retail Sales
Job Printing
Hotel/Motel
Commercial Rental
Wholesaler
Advertising/Publishing
Personal Property Rental
Telecommunications
Manufacturer
Use Tax
Residential Rental # of units _________ (attach list of all rental addresses)
Amusement
Describe Nature of
Contractors #
Business
Cash Receipts
Accrual
# of employees in Mesa
Check method you will use in submitting reports:
Section VI. Business Premises Status
Check one:
Is this a residence?
Do you agree to follow all residential zoning requirements?
Yes
Yes
No
No
Yes
Do you own your business location?
No
If no,complete Landlord/Property Manager information
Landlord/Property Manager Name
Address
Phone #
(
)
Yes
No
Do you rent a portion of the business premises to another entity?
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.
PRINT NAME/TITLE
SIGNATURE (REQUIRED)
DATE
May 2009
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