Permit Renewal Application Form Page 2
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4PERMIT-RENEWAL
prmtrenapp.rev-1/17/13
Please complete all of the fields provided in the form. If the field does not apply to your renewal,
please write NA in the field. If the Trade Name has changed since the last renewal filing you must
also include a filing receipt or a certificate of assumed name with the renewal application.
Other changes noted on the renewal application do not constitute proper notification to the
Authority, nor does the approval of the renewal application constitute approval of any changes
listed in the renewal, other than the Trade Name change.
1. Licensed Premises Information
License Serial #:
Licensed Premises Name:
Trade Name (if applicable):
Effective Date:
Expiration Date:
Federal Employer Identification Number :
Certificate of Authority Number:
Address of the Licensed Premises
If your address has been changed as a result of a 911 change, please provide proof of the change such as notification of the 911 address
change from the local Municipality/Community Board or notification from the Post Office.
Licensed Premises Address:
City:
State:
Zip Code:
County:
Email Address:
Premises Telephone # (include area code):
Contact Phone # (include area code):
Mailing Address (if different than premises address)
Mailing Address:
City:
State:
Zip Code:
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