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City of Washington, NC
Application for Business Privilege License

FISCAL YEAR:

DATE OPERATIONS WILL BEGIN:
TYPE OF BUSINESS:   NEW______    RENEW______    ONE TIME______
BUSINESS NAME:
STREET ADDRESS:___________________________________________________________________
(PO BOX NUMBERS ARE NOT ACCEPTABLE FOR LOCAL BUSINESS ADDRESSES)
MAILING ADDRESS:
CITY: STATE/ZIP:
BUSINESS PHONE: FAX NUMBER:
OWNER'S NAME: MANAGER'S NAME:
NATURE OF BUSINESS (EXPLAIN):
SOCIAL SECURITY NO.: FEDERAL ID NO.:
STATE LICENSE NUMBER, IF APPLICABLE:
IF BUSINESS IS IN CITY LIMITS, TAX PARCEL NUMBER:
GROSS SALES LESS SALES TAX:
RETAIL: $
WHOLESALE: $
MANUFACTURING: $
SERVICE ESTABLISHMENT (GROSS INCOME): $
GS 25-3-506: A $25.00 ADDITIONAL COST FOR RETURNED CHECKS.
GS 105-366(D)(1)(A): REQUIRES NOTIFICATION TO THE TAX COLLECTOR FORTY-EIGHT (48) HOURS PRIOR TO GOING OUT OF BUSINESS. ALSO, REQUIRES NOTIFICATION PRIOR TO THE TRANSFER OF OR PENDING SALE TO ANOTHER PARTY.

AFFIDAVIT
FOR THE PURPOSES OF DETERMINING THE PRIVILEGE LICENSE TAX FOR THE ENSUING TAX YEAR, THE GROSS SALES/GROSS RECEIPTS GIVEN ARE ACCURATE. I UNDERSTAND THAT IT IS UNLAWFUL TO OPERATE A BUSINESS WITHOUT A VALID LICENSE. I ALSO DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE BUSINESS IS IN COMPLIANCE WITH ALL CITY OF WASHINGTON ORDINANCES AND ZONING REQUIREMENTS.

__________________________________               ________________________________
SIGNATURE OR OWNER/OFFICER                      TITLE

SEND TO: CITY OF WASHINGTON, ATTN: PRIVILEGE LICENSE, P.O. BOX 1988, WASHINGTON, NC 27889. PHONE: (252) 975-9324 or 975-9325, FAX: (252) 946-1965.

FOR OFFICE USE ONLY
CUSTOMER NO.: LICENSE NO.:
LICENSE CODE NO.: INVOICE NO.:
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