APPLICANT NAME AND MAILING ADDRESS:
THE INFORMATION PROVIDED IS TRUE AND COMPLETE. I UNDERSTAND MY OBLIGATION FOR THIS LICENSE. BUSINESS LICENSE RECEIPTS ARE
SUBJECT TO AUDIT.
City of Richmond, Virginia
Division of Collections
900 East Broad Street, Room 102
P.O. Box 26505
Richmond, VA 23261-6505
APPLICATION FOR CITY OF
RICHMOND BUSINESS LICENSE
FORM BLR-17
LICENSE YEAR 2017
Account #
IMPORTANT: Renewal application must be filed
and taxes and/or fees paid in full by 3/1/2017.
Your 2016 license expired 12/31/2016.
This license must be surrendered upon demand.
BUSINESS TYPE DESCRIPTION
TAX
RATE
TAX DUE / (REFUND)
–
2016 ACTUAL
GROSS RECEIPTS
2016 TAX DUE 2016 TAX PAID
.00 X =
A
B
2016 – LICENSE TAX ADJUSTMENT – 2016
CALCULATE ADJUSTMENTS ONLY IF YOUR BUSINESS BEGAN AFTER JANUARY 15, 2015
INSTRUCTIONS:
• Type or print only.
• Provide complete information.
• Sign in the space provided at the bottom of the application.
• Return with check payable to “City of Richmond”.
• A 2017 business license will be returned to you.
• For assistance call (804) 646-7000.
• For information or forms, visit our website at www.richmondgov.com.
IMPORTANT — PLEASE READ:
• Up to 10% penalty will be added (subject to a minimum penalty) if
payment is not postmarked or received by the Department of Finance on
or before March 1, 2017.
• Your business must be properly zoned before you may begin operating
(Zoning phone no. (804) 646-6340).
• All trade / assumed names must be registered with the Clerk of the
Circuit Court before the license can be issued (Clerk’s phone no.
(804)646-6530).
• If gross receipts for 2016 were $100,000 or more, please see reverse.
• You will receive a separate renewal form for each line of business or
charge on your account (i.e. Restaurant, Beer & Wine and Mixed
Beverage will produce 3 renewal forms).
TELEPHONE: FAX:
EMAIL ADDRESS:
EMPLOYER NO. OR S.S. NO.:
RICHMOND CITY BUSINESS ADDRESS:
COMPANY:
TRADE NAME:
PRESIDENT:
REGISTERED AGENT:
NO./STREET:
CITY/STATE/ZIP:
TELEPHONE:
A B
DATE CEASED BUSINESS IN RICHMOND: MM DD YY CHECK ONE: q INDIVIDUAL q PART. q CORP. q LLC
LICENSE PREPARER OTHER THAN LICENSEE: FAX #: ( ) -
DATE BEGAN BUSINESS IN RICHMOND: MM DD YY CERT OF OCCUPANCY NUMBER:
SSN OR FED ID#: VA SALES TAX #: TELEPHONE #: ( ) -
Account Number:
2017 – CITY OF RICHMOND – 2017
BUSINESS, PROFESSIONAL, & OCCUPATIONAL LICENSE
Account Number:
CAT TYPE ABC# BUSINESS TYPE DESCRIPTION 2016 GROSS RECEIPTS TAX RATE AMOUNT DUE
.00 X =
LICENSEE:
AMOUNT
PENALTY
T/A:
INTEREST
TOTAL
AMOUNT PAID
Ü
Printed Signature
Date _________ Phone __________________ Name _____________________________ (Required) _____________________________
