Form 8ta-E1 - Business, Professional And Occupational License Application

Form 8ta-E1 - Business, Professional And Occupational License Application - 2005

COUNTY OF FAIRFAX

BUSINESS, PROFESSIONAL AND OCCUPATIONAL LICENSE APPLICATION

DEPARTMENT OF TAX ADMINISTRATION

12000 Government Center Parkway, Suite 223, Fairfax, Virginia 22035

Phone: (703) 222–8234 Fax: (703) 324–3500 or (703) 324–3505 TTY: (703) 222–7594 Web Site:

8. Number of Persons Employed at this Location:

1. Owner Name:*

* Sole Proprietors Use:

Last Name

First Name

Middle Initial

9. Business Contact:

2. Trade Name:

Phone Number:

Fax Number:

3. Federal ID/SSN:

E–mail:

4. Date Business Began in Fairfax County:

10. If Business Operates from Leased Premises:

5. Date Business Ended in Fairfax County:

(a). Annual Rent Paid: $

6. Current Business Location:

(b). Name/Address of Owner of Premises:

7. Mailing Address:

11. Provide a detailed description of business activity:

In completing Boxes 1 through 4 below, all businesses except wholesale merchants must report gross receipts.

Wholesale merchants may report gross purchases in lieu of receipts, if available.

Total 2004 Gross Receipts

BOX 1

Exclusions (See Instructions; Documentation required)

BOX 2

Adjusted 2004 Gross Receipts (Box 1 less Box 2)

BOX 3

If business began after 1–1–04, report gross receipts

estimate for 2005

BOX 4

OFFICE USE ONLY

Account Number

Ordinance

S I C

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

correct to the best of my knowledge and belief.

Print Name/Title:

Reviewed by

Date Received

Signature:

Date:

E-mail:

8TA–E1

PLEASE PRINT CLEARLY

Form 8ta-E1 - Business, Professional And Occupational License Application - 2005

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