APPLICATION
                              CITY OF MADISONVILLE, KENTUCKY
                      MINIMUM OCCUPATIONAL LICENSE FEE

BUSINESS OWNER:

BUSINESS NAME:                                                                  Phone Number:

BUSINESS ADDRESS:

MAILING ADDRESS:                                                                     EMAIL:

FEDERAL ID NUMBER OR SOCIAL SECURITY NUMBER:

BUSINESS CLASSIFICATION:                Individual Owner            Partnership
                                        Corporation                  Other
TYPE OF BUSINESS:

HAVE CITY PLANNING & ZONING REQUIREMENTS BEEN MET?                              Yes        No

NUMBER OF EMPLOYEES WORKING IN CITY:

DATE ACCOUNTING PERIOD ENDS:

DATE BUSINESS BEGAN OPERATING IN CITY:

It is understood that the City of Madisonville has an occupational license fee on net profits from business
conducted within the City.  A minimum license fee must be paid and an annual return filed whether or not
the business has shown a profit.  It is also understood that the license fee must be withheld from earnings
of employees working in the City and remitted to the City quarterly.

DATE:                                   SIGNATURE:

                                                    TITLE:

Optional:
Is your business 51% owned by one or more of the following? Check all that apply
⃝ Female     ⃝ Veteran        ⃝ Minority

Mail to: DIRECTOR OF FINANCE
         CITY OF MADISONVILLE                                       OFFICE USE ONLY
         P.O. BOX 1270
         MADISONVILLE, KY  42431                                    License # Assigned

PLEASE RETURN THIS COPY WITH YOUR                                   I.D. No. Assigned
REMITTANCE OF $ 25.00
PAYABLE TO "DIRECTOR OF FINANCE"                                    Date Issued

                                                                    Initials