CITY OF
PRIVILEGE LICENSE APPLICATION
DATE: ____________ CUSTOMER NUMBER: __________________ (OFFICE)
CUSTOMER NAME: _____________________________________________________
(BUSINESS NAME)
STREET ADDRESS: _____________________________________________________
________________________________________________________________________
(CITY) (STATE) (ZIP)
MAIL ADDRESS: ________________________________________________________
(IF DIFFERENT FROM STREET ADDRESS)
CONTACT PERSON: _____________________________________________________
PARCEL NUMBER: (RENTAL) ____________________________________________
TAX I.D. NUMBER: ______________________________________________________
PHONE NUMBER: _______________________________________________________
FAX NUMBER: _________________________________________________________
BUSINESS DESCRIPTION: _______________________________________________
________________________________________________________________________
OFFICE USE ONLY
STATUS: ____________________
INSPECTION CYCLE: __________ INSPECTION RESULTS:_______ DATE: ______
CAT: __________________ AMOUNT: _____________________
YOUR LICENSE MAY BE MAILED TO YOU. PLEASE CONTACT US AT 336-349-1054 IF YOU HAVE ANY QUESTIONS.
THANK YOU.