License Application

Town of Collinsville P.O. Drawer N 39 Post Office Street Collinsville , Alabama 35961
Telephone 256-524-2135 Fax 256-524-2121

1.     FEIN _______________________    or Social Security No. ________________________________
2.     Type of Business Organization
        Corporation            Sole Proprietorship        Partnership
        Professional Association        Other ______________________________________________________
3.     Physical Location: City______________________________ County _________________________ St ______
        Inside City Limits        Outside City Limits but within Police Jurisdiction
4.     Indicate the type of tax and rate you will be filling (mark all that apply):
        Sales Tax            Seller's Use Tax           Consumer Use Tax           Other___________________
        General Rate                   Automotive Rate                  Mfg Machine Rate
        Agricultural Rate        Amusement Rate                 Vending
5.     Indicate the jurisdictions you will be filing tax in:
        Collinsville, ________________________________________________________________________________
6.     Taxpayer Information (all below information is required!):

Taxpayer name:	___________________________________________________________________
DBA:	___________________________________________________________________
Contact Person:	_________________________________________	Title:____________________
Mailing Address:	___________________________________________________________________
City/State/Zip:	___________________________________________________________________
Email Address	___________________________________________________________________
Street Address:	___________________________________________________________________
City/State/Zip	___________________________________________________________________
Telephone:	___________________________________________________________________
Fax:	___________________________________________________________________
Begin Date:	___________________________________________________________________
SIC Code:	___________________________________________________________________

Signature ________________________________________ Title____________________ Date__________

1.	Business Name:	________________________________________________________________________________
2.	Trade Name or DBA:	________________________________________________________________________________
3.	Business Address:	________________________________________________________________________________
4.	City/State/Zip:	________________________________________________________________________________
5.	Primary Contact:	________________________________________________________________________________
6.	Primary Phone:	__________________________________________
7.	Fax:	__________________________________________
8.	Emergency Phone:	__________________________________________
9.	Business Type:	Retailer Wholesaler Manufacturer Contractor
9.	Business Type:	Other _____________________________________________________________________
10.	No. of Employees:	__________
11.	Ownership Type:	Corporation Partnership Proprietorship Prof. Assoc.
11.	Ownership Type:	LLC Other _________________________________________________________
12.	Fed. Tax I.D. or SSN:	_______________________________________
13.	AlaTax Acct. No:	_______________________________________
14.	Jurisdiction:	Town Limits Police Jurisdiction (do not mark if unknown)
15.	Begin Date	__________________ (required on applications for NEW licenses ONLY!)
16.	Owner Name:	_______________________________________________ (or name of other responsible person)
17.	Title:	_______________________________________________
18.	Telephone:	_______________________________________________
19.	Address:	________________________________________________________________________________
20.	City/State/Zip:	________________________________________________________________________________
21.	Business Mailing Addr:	________________________________________________________________________________
22.	City/State/Zip	________________________________________________________________________________
23.	Secondary Contact	________________________________________________
24.	Description of Business activities in Collinsville:____________________________________________________________
	_____________________________________________________________________________________________________
25.	If you are a contractor, how will your contract materials be delivered to the Collinsville jobsite?
	Delivered by supplier Withdrawn from inventory N/A
26.	Do you have sales persons who personally solicit business in Collinsville? YES NO
27.	How are your goods delivered to Collinsville? Company-Owned /Leased Vehicles Common Carrier N/A
28.	How many Business License decals are needed for vehicles operating in Collinsville? __________
29.	If business activities are to include retail sales, will any of the following be sold or provided? (mark all that apply)
	Agricultural Machinery Appliances Auto Parts or Accessories
	Automobiles, Trucks, other motor vehicles, including trailers, semi-trailers, mobile homes
	Building Materials Concrete or Concrete Products Electrical Supplies
	Firearms or Ammunition Fireworks Furniture Gasoline, other Motor Fuels
	Greeting Cards Groceries Ice Ice Cream Meat, Fish, or Poultry
	Milk or Milk Products Plumbing Supplies Propane or Butane Soft Drinks
	Tapes or CDs Tire Re-Capping Tires Tobacco Products Video Rental
30.	If your business activities include both retail and wholesale sales, what percentage comprises each activity?
	Retail _____% Wholesale _____% Sales to Government Agencies _____% N/A
31.	Other than wholesale sales and sales to government agencies , do you sell any merchandise or provide any service for which a sales tax is NOT collected?
	YES NO (if "YES" attach a list of such goods and/or services) N/A
32.	Will your business activity include use of any of the following? (mark all that apply, use additional sheets if necessary)
	How Many? Location Address (attach additional sheets is necessary)
	Pool or Billiard Tables? _________ _____________________________________________________
	Coin-op Laundry Machines? _________ _____________________________________________________
	Coin-op Vending Machines? _________ _____________________________________________________
	Coin-op Amusement Machines? _________ _____________________________________________________
	Popcorn Machines? _________ _____________________________________________________
	Soda Fountains? _________ _____________________________________________________
33.	Appendix A (Statement of Gross Receipts) attached? YES N/A
Under penalty of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it is true, correct and complete. My signature indicates that I take full responsibility for this application and any tax liability and/or penalty that might occur or be imposed as the result of business activities in the Town of Collinsville, Alabama as related to the business for which license is applied for. Print Name of Owner, Partner, or Officer______________________________________ Title__________________________ ^{(or other responsible person)} Signature of Owner, Partner, or Officer______________________________________ Date_____________ ^{(or other responsible person)} Privacy Notice: The information provided herein is made available only to those specifically authorized and responsible for the administration and enforcement of the Town’s Business Privilege License Ordinance and other related regulation and is not released or otherwise provided to any other person or agency except by order of a court of competent jurisdiction.