APPLICATION FOR OCCUPATIONAL LICENSE

(License year July 1st through June 30th)

SECTION I:  IDENTIFICATION INFORMATION

1.  Name of establishment _______________________________________________________________

     Phone:  Business Hours ________________________  Emergency Phone ______________________

2.  Missouri State Sales Tax Number _______________________________________________________

3.  Business Address ______________________________________________________  Zip _________

4.  Home Office Address, if any __________________________________________________________

5.  Ownership:  Individual ______________  Partnership _______________  Corporation ____________

6.  If corporation, name of State where incorporated ___________________________________________

7.  Do you conduct commercial activities on the premises using names other than that for which you are making application? _____________.  If answer is yes, please list names below:

_____________________________________________________________________________________

8.  Date of last completed fiscal year (Calendar year if also fiscal year) preceding the license year beginning July 1st, as established and used for Federal Income Tax purposes:  ______________________

Date Business began operations in City of Clarkson Valley:_____________________________________

9.  Nature of activity:  (Merchant or specific occupation or business.  Describe activity in sufficient detail to indicate type of business.  For example is a product sold, or a service, or both; and what is product or service?):  ____________________________________________________________________________

_____________________________________________________________________________________

10.  Name and address to which correspondence and renewal notice should be sent: _________________

____________________________________________________________________________________

11.  Number of employees:  ______________________________________________________________

12.  Number of automobiles entering City of Clarkson Valley daily as a result of this operation:  _______

SECTION II:  FEE:            $25.00/ANNUM

SECTION III:  CERTIFICATION

_________________________________, hereby certifies that he/she is ___________________________

                                                                                                            (owner, partner, title of officer)

named firm, and is familiar with the operations of the applicant and the facts set out above and that they are true and correct according to the best of his/her knowledge, information and belief.

                                                                        _____________________________________________

                                                                        Signature

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FOR CITY USE ONLY

Application and fee $ ________  Received by _______________________________  Date ___________

License issued by ______________________________________________________  Date ___________