CITY OF NEWPORT NEWS
Commissioner of the Revenue
Business License Department
Main Office: 2400 Washington Avenue, Newport News, VA 23607
Satellite Office: 12912 Jefferson Avenue, Newport News, VA 23608
Phone # (757) 926-8651 Fax # (757) 247-2628
List Officer(s), Partner(s) and/or Member(s) of the Entity, as Registered with the
Virginia State Corporation Commission:
BUSINESS NAME: ______________________________________________ ACCOUNT # _______________
NAME: ________________________________________________TITLE: _______________________________________
SOCIAL SECURITY NUMBER: __________________________ PHONE NUMBER: _____________________________
COMPLETE RESIDENTIAL ADDRESS: _________________________________________________________________
_____________________________________________________________________________________________________
NAME: ________________________________________________TITLE: _______________________________________
SOCIAL SECURITY NUMBER: __________________________ PHONE NUMBER: _____________________________
COMPLETE RESIDENTIAL ADDRESS: _________________________________________________________________
_____________________________________________________________________________________________________
NAME: ________________________________________________TITLE: _______________________________________
SOCIAL SECURITY NUMBER: __________________________ PHONE NUMBER: _____________________________
COMPLETE RESIDENTIAL ADDRESS: _________________________________________________________________
_____________________________________________________________________________________________________
NAME: ________________________________________________TITLE: _______________________________________
SOCIAL SECURITY NUMBER: __________________________ PHONE NUMBER: _____________________________
COMPLETE RESIDENTIAL ADDRESS: _________________________________________________________________
_____________________________________________________________________________________________________
NAME: ________________________________________________TITLE: _______________________________________
SOCIAL SECURITY NUMBER: __________________________ PHONE NUMBER: _____________________________
COMPLETE RESIDENTIAL ADDRESS: _________________________________________________________________
_____________________________________________________________________________________________________
The Officer(s), Partner(s) and/or Member(s) Information Provided and Completed by:
Print Name: _______________________ Signature: _________________________Date: __/___/____
