District Of Columbia Form - Department Of Licenses & Inspections

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DEPARTMENT OF LICENSES & INSPECTIONS
LICENSE ISSUANCE SECTION
1401 John F. Kennedy Boulevard • Concourse
Philadelphia, PA 19102
APPLICATION FOR LICENSE/REGISTRATION
COMPLETE NUMBERED ITEMS AS APPLICABLE
(NO., STREET, ZIP)
1.) BUSINESS NAME
2.) BUSINESS/LICENSED LOCATION
*
(IF CORPORATION OR PARTNERSHIP, SEE BELOW)
(NO., STREET, CITY, STATE, ZIP)
3.) OWNER’S NAME
4.) MAILING ADDRESS
EMPLOY.
5.) TYPE OF BUSINESS
6.) DATE BUS. STARTED
7.) FEDERAL
8.) STATE
IDENT.
NUMBERS
(BUSINESS)
(HOME)
9.) TELEPHONE
10.) TELEPHONE
OFFICIAL USE
CODE NO.
DESCRIPTION
FEE
3702
BUSINESS PRIVILEGE LICENSE
$200.00
(ENGINE NO. & MAKE OF
APPROVALS
OTHER DATA
REGIS/LIC. NO.
VEHICLES INVOLVED, ETC.)
BUS. PRIV. LIC. NO.
BUS. PRIV. LIC. TAX NO.
*
11.) NAMES & ADDRESSES OF CORPORATION OFFICERS OR PARTNERS
NAME & TITLE
RESIDENCE ADDRESS
SOCIAL SECURITY #
Mail the completed application and a check or money order for $200 to:
CITY OF PHILADELPHIA
DEPT. OF LICENSES & INSPECTIONS
LICENSE ISSUANCE UNIT
1401 JOHN F. KENNEDY BOULEVARD
PHILADELPHIA, PA 19102
I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief.
I understand that if I knowingly make any false statement herein I am subject to such penalties as may be prescribed
by law or ordinance.
Applicant Signature
Date:
Print Name Clearly
Sheet I

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