2015 Business License Application Form - Town Of Warsaw, Virginia Page 2
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2TOWN OF WARSAW, VIRGINIA
2015 Business License Application
78 BELLE VILLE LANE
P. O. BOX 730
WARSAW, VA 22572
Phone (804) 333-3737
Fax (804) 333-3104
ST
FILE AND PAY BY MARCH 1
TO AVOID A 10% LATE PAYMENT PENALTY
Read the instructions for important dates and penalties. Mail or deliver the completed application and payment to the above address.
A Legal Name/Address (mailing)
____________________________________
C _____________________
H Type Business (Check)
Driver’s License # or
____________________________________
____________________________________
Social Security Number
Social Security #
____
Individual
____________________________________
D _____________________
____
LLC
____________________________________
Telephone Number
____
Partnership
B Trade/Business Name and
E _____________________
____
Corporation
Physical Location
State ID Number
____________________________________
F _____________________
Start Date of Business
____________________________________
Federal ID Number(if any)
____________________________________
G ______________________
__________________
____________________________________
Customer Number
1 State Contactor’s License (circle one): A
I
B
C
Expiration Date: _________________
2 State Contractor’s License Number:_____________________
3 VWC FORM 61-A Must be attached to Business Application. Check here if attached _____
Unless otherwise indicated report your prior year total gross receipts. If you were not in business one full
calendar year, you must provide an estimate of gross receipts for the current tax year in addition to your
prior year gross receipts per the following applicable category or categories:
Prior Year
Estimated
Tax
Amount
Gross Receipts
Gross Receipts
Rate
Due
1. Contractor
$ __________
$___________
$_____
$_________
2. Retail
$__________
$___________
$_____
$_________
3. Professionals
$__________
$___________
$_____
$_________
4. Repair,Personal &
Business Service
$__________
$___________
$_____
$_________
5. Wholesalers *
$__________
$___________
$_____
$_________
(*List Your Purchases on this Line)
6. Financial Services
$__________
$___________
$_____
$_________
7. Real Estate
$__________
$___________
$_____
$_________
8. Peddler’s
$__________
$___________
$_____
$_________
9. Flea Market Vendor $__________
$___________
$_____
$_________
10. Others
$__________
$___________
$_____
$_________
11. Telephone Comm. $__________
$___________
$_____
$_________
I hereby swear or affirm that all the information listed above is true and correct to the best of my
knowledge. License Figures are subject to audit of IRS forms and may be requested for verification.
_________________________ __________________________
____________
Signature of Applicant
Printed Name
Date
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Parent category: Business