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Form 8ta-E1 - Business, Professional And Occupational License Application - County Of Fairfax - 2016

2016

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 Online:

8. Number of Employees at This Location:

1. Owner Name:*

Sole Proprietor’s 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/Phone Number of Owner of Premises:

7. Mailing Address (if different from location):

11. Provide a detailed description of business activity conducted in Fairfax County:

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 2015 Calendar Year Gross Receipts

BOX 1

NAICS Code

12.

Exclusions (See Instructions; Attach Exclusion

BOX 2

form and required documentation).

13. Contractors, Builders & Developers, Architects and Engineers:

Adjusted 2015 Gross Receipts (Box 1 less Box 2)

State License #:

BOX 3

Expiration Date:

If business began after 1–1–15, report gross receipts

BOX 4

Required For Retail Merchants Only:

14.

estimate for 2016 (after allowable exclusions)

Sales Tax Locality Code:

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

Sales & Use Tax Account #: _________________________________

to the best of my knowledge and belief.

OFFICE USE

Print Name/Title:

ONLY

Account Number

Ordinance

NAICS

Signature:

Date:

E-mail:

Reviewed by

Date Received

8TA-E1

PLEASE PRINT CLEARLY AND SEE REVERSE SIDE FOR INSTRUCTIONS.

Nov. 2015

Form 8ta-E1 - Business, Professional And Occupational License Application - County Of Fairfax - 2016

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