Application For Brevard County Business Tax Receipt (Page 2 of 3) in pdf

APPLICATION FOR BREVARD COUNTY BUSINESS TAX RECEIPT

COMPLETE THIS SECTION: (Print or Type)

Original Application

Transfer / Correction of Existing Tax Receipt

1. BUSINESS NAME:

__________________________________________________________________________________

Individual Professionals: Skip Line #1

BUSINESS NAME = Trade Name D/B/A

2. OWNER(S):

______________________________________________________________________________________

3. TELEPHONE:

Business: ______________________________

Cell: ___________________________________

Home: ________________________________ Fax: ___________________________________

4. LOCATION:

________________________________________________________________________________________

[Physical Street Address; NOT a P.O. Box ]

IS THE SUBJECT PROPERTY WITHIN CITY LIMITS?

IF YES, CITY RECEIPT # ___________________

YES

IF NO, COMPLETE ZONING VERIFICATION SECTION ON BACK PAGE: (Brevard County Zoning Div. Ph # 321-633-2070)

MAILING ADDRESS: __________________________________________________________________________________

6. OPENING DATE OF BUSINESS, OR DATE BUSINESS ASSUMED OR RELOCATED: ___________________________

7. FLORIDA SALES TAX REGISTRATION # _______________________________________ (If Applicable)

8. FIN # _______ - _____________________________ OR SS# _______________________________________ *

9. CERTIFICATION OR STATE BOARD # ________________________________________________________________

(CONTRACTORS, PROFESSIONALS, ETC.)

10. NATURE OF BUSINESS:

_________________________________________________________________________________________

(SPECIFY ACTIVITY / ACTIVITIES, TYPE OF SALES OR SERVICE)

11. DO YOU APPLY FERTILIZER TO TURF AND/OR LANDSCAPE PLANTS?

YES

(See Instructions & Information Sheet for more information.)

12. EMAIL:

______________________________________________ WEBSITE: ______________________________________________________

ACKNOWLEDGMENT:

Issuance of a Brevard County Business Tax Receipt DOES NOT certify compliance with related Florida Laws or Brevard County

Ordinances. Although regulatory requirements for specified activities may have been required by Statute, failure to disclose specific activities

(on line 10) may result in insufficient determination of known pre-requisites. Although zoning verification may have accompanied this application,

specific violations are not defensible by issuance of this tax receipt.

Services, construction related activities, and other shall be responsible for determining the limitations of activities which otherwise require

regulatory compliance (i.e. "Handyman" prohibited from Electrical, Plumbing, Roofing, etc. which requires Certificate of Competency, or State of

Florida Certification). The Brevard County Business Tax Receipt shall be subject to revocation upon notification by appropriate Regulatory

Agency, or knowledge by Tax Collector (& employees) that activities are engaged in which require Regulatory compliance, until such Regulatory

requirement is fulfilled, or until prohibited activity ceases.

* Pursuant to Florida Statute 119.071(5)(a)2.a, the purpose for the Tax Collector’s collection of an individual’s social security number for

this application is to comply with Florida Statute 205.0535(5) which requires that no local business tax receipt be issued unless the social

security number is obtained from the person to be taxed.

I hereby declare the information submitted herein to be true to the best of my knowledge, and that I have read the above acknowledgment.

APPLICANT’S SIGNATURE X ____________________________________________________ DATE________________________

Identification (Driver Lic. # etc) _______________________________________________

Florida Driver’s License, notarized acknowledgment, Corporate Charter Receipt from Secretary of State. If application is completed by other than owner(s)

[including ALL partners], a copy of the organizational documents must be included. (i.e. partnership agreement, Corporate charter, etc.)

DO NOT WRITE IN THIS BLOCK: TAX COLLECTOR’S USE

Ownership

Location

TRANSFER:

*SUBMIT COPY OF CURRENT RECEIPT

ACCOUNT #

______________________

RECEIPT AMOUNT

$0.00 (if paid)

EXEMPTION

______________________ City Code ________

TRANSFER OF

$5.00

CLASSIFICATIONS:

CERTIFICATION#

OWNERSHIP

________________________

____________________

________________________

____________________

________________________

____________________

TOTAL DUE:

$5.00

________________________

____________________

Mailed / Distributed by: __________ Date: ___________

WEBSITE

Advised of T.P.P. (Acct #): _____________ Issued By: ___________ Date: __________

Application For Brevard County Business Tax Receipt Page 2

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