S:\Office Documents\Forms-Affidavit\FORMS 2007\License_Form 2014 15 JM.doc
PLEASE PRINT OR TYPE (BLACK / BLUE INK ONLY) NO CORRECTION FLUID ALLOWED
1. Business Name ________________________________________ Date of Application ________________
Owner’s Name/Corporation Name ________________________________________________________________
2. Location of Business ______________________________________________________________________
ADDRESS BAY, SUITE, APT. NO., CITY, ZIP TELEPHONE
Mailing Address __________________________________________________________________________
(If different from above) ADDRESS BAY, SUITE, APT. NO., CITY, ZIP FAX: TELEPHONE
3. Driver’s License # ________________________ Date of Birth ____________ Expiration Date _____________
4. Name of Member/Officer of the Corporation, LLC, LP, Fictitious Name etc. (President, V.P., MGR, etc.)
(A) Name _______________________________________________________Cell-Phone_________________
(B) Home Address_______________________City____________Zip_______Home Phone________________
(C) Emergency Contact _____________________________________ Telephone: _______________________
(D) E-Mail Address: _______________________________________
5. If a firm or Corporation, the name, address, city, zip and home phone number of the Officers
* ____________________________________ *________________________________________________
* ____________________________________ *________________________________________________
6. Type of Business Manufacturer Wholesale Retail Service Other_________________________
SPECIFIC Products or Services: A) ___________________________________________________________
B) ____________________________________________________________________________________
7. Number of seats, work stations or units:______
8. If Business is operated from vehicle: Number of vehicles_____ Registration No.’s_______________________
I affirm that the above is true and correct to the best of my knowledge. I am aware of penalties and/or revocation of license for false statements.
_________________ ____________________ ____________________ ___________________
TITLE OF APPLICANT NAME OF APPLICANT SIGNATURE AND SEAL DATE
BUSINESS TAX RECEIPT NUMBER A) TOTAL FEE $
New Renewal
Transfer of ownership B) Basic Fee $ ____________
Transfer of Location Unit Fee $ ____________
Change of Name/Mailing Address ZONING Transfer Fee $ ____________
___________________________ CLASSIFICATION Delinquent Fee $ ____________
Forfeit Fee $ ____________
Other Fee $ ____________
NEED COPIES OF ITEMS CIRCLED: DECAL NUMBER___________________ Fire Fee $ ____________
Driver’s License State License Tax ID
Fire Inspection Agricul.-Hotels-Rest CC Dade
Bill of Sale (Notary) Insurance Sworn Affidavit (Notary)
Articles of Corp Police Background Vehicle Registration
______________________ ______________________
Application processed by___________________ Date___________ Inspected by_________________ Date____________
