APPLICATION TYPE:
City of Madison
Business
License & Tax Application
P.O.
Box 99 Madison, Alabama 35758
Phone 256-772-5654 Fax 866-591-8740
revenue@madisonal.gov
Physical Address: ____________________________________________________________________________________________
FAX
NAME TITLE SOCIAL SECURITY NUMBER
PHONE
Email Address __:
____
________________________________________________________________________________________
Telephone:(_______)________________________(_______)_______________________
(_______
)__________________________
Name/Phone Contact Person: ___________________________________________________________________________________
Names of Owner(s), Partner(s), or Officer(s) Use back or attach separate sheet if necessary:
____
______________________________________________________________
_________________________ ______
____________
______
____________________________________________________________________________________ _________________
NAME TITLE SOCIAL SECURITY NUMBER
PHONE
Description of Work: ______
____________________________________________________________________________________
Estima
ted gross receipts: $ ________________________________________
License amount $ __
___________
Tota
l amount due $______________
This Application has been examined by me and is to the best of my knowledge a true and complete representation of the above
named entity and person(s) listed.
Signature o
f Applicant ___________________________________________________________________________________
Title __________________________________________________________ Date ___________________________________
Date ________________
ID __________________
Payment _____________
Amount ______________
CONTRACTOR INFO:
Date
work begins _______________________________________ Contract Amount $ ______________________________________________
Job Location __________________________________________________________________________________________________________
If Sub, Name of General Contractor _______________________________________________________________________________________
NAICS Code(s)
____
____
_______________________________________
Tax: Sales Use Rental Lodging Liquor Tobacco Gas
Filing: Monthly Quarterly Occasional Other
Do you need reasonable accommodation to complete this form? If so, please call 256-772-5654
street
str
eet
city
city
state
state
zip code
zip code
Business License
Tax Account
Location Change
Name Change
Owner Change
PLEASE PRINT OR TYPE
Legal Business Name: ____________________________________________________ EIN, State ID, or SS # __________________
D.B.A. (if different from above): ________________________________________________________________________________
Mailing Address: _____________________________________________________________________________________________
WORK HOME/CELL
Number of Employees: ____
____________________________________________________________________________________
Organization Type: Corp
oration LLC Partnership Sole Proprietor
Issue Fee: $ 12.00
SUBMIT
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signature
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