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BUSINF S LICENSE APPLICATION -•Z,�} STAFF ACTION ,_1---
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IN ANNUAL FEE BOX AT RIGHT. PENALTY DUE ON RENEWALS S 5.00 LIC. EFFEC. DATE REASG. LIC. N0.sPl
RECEIVED BY CITY CLERK AFTER FEBRUARY 15. SMALL 8 5. 7.50 2. NEW .BUSINESS: COMPLETE ALL LICENSE APPLICATION BOXES. °GENERAL C 5�00 25.00
LIC. RENEWAL: REVIEW LICENSE INFORMATION BELOW. PRINT RECEIPT NO. DATE PAID
CORRECTIONS AND ADDITIONS AT RIGHT. 'OVER 10 EMPLOYEES, OR EMPL WORK PRINT 'X'
OVER 120 MAN -MONTHS PER YEAR. IN SPEC. BO)
3. SIGN AND RETURN APPLICATION WITH FEE (AND PENALTY). FOR ISSUE 0!
4. LICENSE WILL BE MAILED TO YOU UNLESS YOU ARE NOTIFIED CLASS FEE PAID ! PENALTY PAID FEE PAID PENALTY PAID C 0 R R E C T E 11
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NAME SOCIAL SECURITY NO.
DATE OF BIRTH PLACE OF BIRTH
HOME ADDRESS
3. BUSINESS IDENTIFICATION
BUSINESS NAME
NATURE OF BUSINESS BUSINESS PHONE
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5. EMERGENCY NOTIFICATION
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NAME
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