City of
OCCUPATIONAL TAX
CERTIFICATE APPLICATION
Section One (To Be
Completed By Applicant)
Date:
_____________________________________________
Name of
Business___________________________________________________
Mailing
Address______________________________________________________________
Location of
Business: _______________________________________________________
Property Owner:
__________________________________________________________________
Describe Principle
Type of Business Conducted: ______________________________________________ Phone Number___________________
Federal
Date Business Started: _______ Maximum Number of
Employees: ___________
Note: Please include all full-time and part-time staff. The number
of employees shall be determined from your State Employment Security Report.
I hereby certify that the information reported herein is true and
correct to the best of my knowledge.
Print Name:
____________________________________ Title:
__________________________________________
Signature: ________________________ Date:
____________________________
Address:
__________________________________________________________________________
***************************************************************************************************************************************************************************
Section TWO (To Be
Completed By City Staff)
Administrative Fee______________________________
Occupational Tax Fee ___________________________
TOTAL DUE TO THE
Building Official Signature:
________________________
Please Return to:
City of
Nicholson, Georgia 30565