CITY OF LEESVILLE

FINANCE OFFICE

101 WEST LEE STREET

LEESVILLE, LA 71446

PH: (337)239-2046/2866   FAX: (337) 239-8030

APPLICATION FOR OCCUPATIONAL LICENSE

Date of Application:___/___/___                   Date Opened:___/___/___

APPLICATION IS REQUIRED FOR: (check one)

NEW BUSINESS	O	NAME OF PRIOR OWNER:
PURCHASE OF EXISTING BUSINESS	O	NAME OF PRIOR BUSINESS:

NATURE OF BUSINESS-DESCRIPTION OF SALES OR ACTIVITIES:

_______________________________________________________________________________________________

BUSINESS NAME:	BUSINESS PHONE:
OWNER'S NAME (Name of individual, partners or corporation): POINT OF CONTACT'S NAME:	E-MAIL ADDRESS:
	PHONE NUMBER:

LOCATION ADDRESS	STREET NO.           STREET NAME      APT./SUITE        CITY/STATE          ZIP
MAILING ADDRESS	P.O. BOX OR STREET NO.         STREET NAME    APT/SUITE   CITY/STATE     ZIP

1. TYPE OF OWNERSHIP     O PARTNERSHIP	O INDIVIDUAL          O  NON-PROFIT
O CORPORATION	O GOVERNMENTAL     O OTHER SPECIFY:__________

BUSINESS AUTHORIZATION/I.D. NUMBERS (IF APPLICABLE):

A. CERTIFICATE OF OCCUPANCY NUMBER

B. LOCAL SALES & USE TAX NUMBER

C. LOUISIANA STATE I.D. NUMBER

D. FEDERAL EMPLOYER I.D. OR OWNER'S SOCIAL SECURITY NUMBER

E. NON-PROFIT 501 (C) NUMBER

OFFICERS/OWNERS:

BUILDING OWNER'S NAME:

TITLE:

RESIDENT ADDRESS:

TELEPHONE NUMBER:

MAILING ADDRESS:

TELEPHONE NUMBER:

NEW BUSINESS

CLASS

TABLE

CLASS DESCRIPTION

QTY

AMOUNT

CHAIN STORES:

TOTAL STORES:

LOCAL STORES/UNITS:

	PAYMENT TYPE (CASH/CHECK#)
TOTAL DUE:

I affirm that the information given on this application is true and correct.   I will report any change in business ownership, operation, and/or address immediately.

______________________________________                                   __________________

SIGNATURE OF APPLICANT                                                        DATE

______________________________________                                   __________________

SIGNATURE OF PREPARER                                                         DATE