CITY OF JEFFERSONTOWN
BUSINESS LICENSE REGISTRATION
Pursuant to City Ordinance No. 1233, Series 2008, persons, firms or organizations engaged in any trade
or profession operating in the City of Jeffersontown for profit or gain, to first register with said City.
PLEASE COMPLETE, SIGN, DATE & RETURN WITH $75.00 ANNUAL FEE TO CITY HALL
WITHIN 10 DAYS OR UPON START-UP OF BUSINESS
Type or Print PLEASE ANSWER ALL QUESTIONS Type or Print
1. Name(If registering as individual): ___________________________________________________________________
2. Corporate or Limited Liability Company (LLC) Name: ___________________________________________________
3. Trade Name or D.B.A. (If dierent from above): _________________________________________________________
4. Primary Corporate / Business Address
Street:__________________________________________________ Phone:_________________________________
City, State, Zip:___________________________________________ Fax:___________________________________
4a. Local Jeersontown, Kentucky Address (if any)
Street:__________________________________________________ Phone:_________________________________
City, State, Zip:___________________________________________ Fax:___________________________________
5. Fed Tax I.D.:______________________________________ 6. If Non-Prot, Tax Exempt #:_______________________
7. Enter Social Security Number (SSN) if Individual, Sole Proprietor or Single Member LLC:_________________________
8. Email Address:____________________________________ 9. Website:______________________________________
10. Nature of Business:____________________________________________11. NAICS #:__________________________
12. Date business started or will start in Jeersontown:___________________13: Number of employees:______________
14. Complete it obtaining a previously established business, or if there is a change in the organization has occurred:
Date of change:________________________________ Date employment began:_____________________________
Former corporate of busines name:__________________________________________________________________
IF BUSINESS EMPLOYS PEOPLE IN JEFFERSONTOWN, THE EMPLOYER MUST FILE QUARTERLY
OCCUPATIONAL TAX RETURNS WITH THE CITY OF JEFFERSONTOWN REVENUE DEPARTMENT
15. Payroll Service Provider:__________________________________________________________________________
Phone:__________________________ Fax:_________________________ Contact:__________________________
16. Corporate / Business Payroll Contact:________________________________________________________________
Phone:__________________________ Fax:_________________________ Contact:__________________________
17. For additional information or in case of emergency contact:
Name:________________________________________________________ Phone:__________________________
**PLEASE NOTE** It is the applicant’s responsibility to inform the Revenue Department of any changes in ownership,
addresses, number of employees or termination of business activity. The undersigned (business) agrees to be responsible
for all collection costs and attorney’
s fees in connection with any delinquent account.
Signature:________________________________________________________ Date:___________________________
(FOR OFFICE USE ONLY): Account #’s:________________________________________________________________________
□ ABC Licensed
□ inancial Institution □ Governmental Agency □ Non-Profit □ Insp. / Permit
Revenue Department
10416 Watterson Trail ▪ Jeffersontown, KY • 40299-3749 • Phone: (502) 267-8333 • Fax: (502) 267-0547 •
jeffersontownky.gov
rev. 20210107
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