Privilege License Application
(This form must be filled in completely.)

1. Name of Business:  ___________________________________________________________

2. Business Mailing Address:  ___________________________________________________

3. Business Location:  __________________________________________________________

4. Business Phone:  _____________________________________________________________

    Fax:  ___________________________________________________

5. Tax ID #:  ___________________________________________________________________

6. Is this business a branch or chain store?  ___________________________________

7. Owner(s) of Business:

     _____________________________________________________________
       Print Name                                      Signature

8. Owners Phone #:  _____________________________________________________________

9. Type of Business:  ___________________________________________________________

10. Description of Business (Retail, Wholesale, Services Rendered, etc.):  ______

11. Please enter your most recent annual gross sales figure. If this is a new business, enter estimated figure.
Privilege License fees are based on gross annual sales. :

      $ ___________________________________