Form B-202a - Application For State Privilege License
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2B-202A
Application for State Privilege License
North Carolina Department of Revenue
Web
12-12
For Office Use Only
For the year beginning July 1,
and ending June 30,
First-Time Applicant
If first-time applicant, enter start date of activity that requires this license.
Renewal Applicant
If renewal applicant, enter account number/NCDOR ID for this license.
Professional Individuals
Part 1.
First Name
M.I.
Last Name
Social Security Number
Daytime Phone
(Include area code)
Name of Business Where Professional Individual Is Employed (optional)
Address Where License Is To Be Mailed (This address is printed on the license.)
Zip Code
City
State
County
(5 Digits)
Enter Code Number and License Description from Table on Reverse
Loan Agencies, Check Cashers, or Pawnbrokers
Part 2.
Loan Agency
Check Casher
Pawnbroker
Legal Name of Business
Federal Employer ID Number
Business Phone
(Include area code)
Street Address of Business
Zip Code
City
State
County
(5 Digits)
Address Where License Is To Be Mailed (If different from street address)
Zip Code
City
State
(5 Digits)
Part 3.
Computation of Privilege License Tax
.
1. Total Privilege License Tax Due
(From Table on Reverse)
.
2. Penalty
.
3. Interest
.
$
,
4. Total Payment Due
(Add Lines 1 through 3)
Signature:
Date:
I certify that, to the best of my knowledge, this application is accurate and complete.
Attach your check or money order to this application. Payment must be in the form of U.S. currency from a domestic bank.
North Carolina Department of Revenue, P.O. Box 25000, Raleigh, NC 27640-0100
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