CITY OF OWENSBORO/DAVIESS COUNTY FISCAL COURT
                 OCCUPATIONAL BUSINESS LICENSE APPLICATION
                                                  P.O. BOX 10008
                                        OWENSBORO, KY  42302
                                                   (270) 687-5600

NOTE: IF YOU HOLD A CURRENT CITY OF OWENSBORO BUSINESS LICENSE IT IS NOT NECESSARY TO APPLY  
      FOR A DAVIESS COUNTY FISCAL COURT BUSINESS LICENSE.
1. APPLICANT INFORMATION

     NAME OF APPLICANT

     TRADE NAME OR DBA

2. OWENSBORO/DAVIESS COUNTY LOCATION INFORMATION
How many locations will this business operate from        ? If more than one, attach a Location Information form,
giving the address of each location. The Location Information form is available upon request.
ADDRESS
       Owensboro/Daviess County Location (Street)                                Zip Code
Business Phone#_____________________________              Email Address:

Mailing Address( if different from Owensboro/Daviess County Location)

Street                                               City                       State               Zip Code

3. CHECK TYPE OF OWNERSHIP                         Corporation          Sole Proprietor                  Partnership
       LLC       (Sole Proprietor)                   LLC (Partnership)                LLC  (Corporation)
               *NOTE:  Other Business entities may be required to obtain an Occupational Business License

4. CORPORATION INFORMATION
If applicant is a corporation, please list corporate name exactly as it appears on your federal income tax return.

Corporate Name                                                          Date of Incorporation

5. OWNER(S) OF BUSINESS
If an individual, give name, date of birth, residence address, and social security number; If a partnership,  
give this information for each partner; If a corporation, give the same information for the President, 
Vice President, Secretary and Treasurer.
Name                                                      Date of Birth               Social Security #

List duly authorized representative of the business who is responsible for operating and managing the business in Owensboro/Daviess County:

Name                                    D.O.B.               S.S.#                      Title

Residence Address

Home Telephone #                                               Night Emergency #

6. ACCOUNTING PERIOD

           Calendar Year    Fiscal Year            /      to          /        (please specify beginning of year) 

7. IDENTIFICATION NUMBERS

Enter any of the following identification numbers which apply to your company:
FEDERAL EMPLOYER I.D. NUMBER  ________ - _______________________
SOCIAL SECURITY NUMBER (If you are sole proprietor)

8. PAYROLL WITHHOLDING FEE

A.) Will you have employees working in the corporate city limits of Owensboro? ____ YES ____ NO 
B.) Will you have employees working in Daviess County, outside the corporate city limits of Owensboro? ____ YES ____ NO
C.) First Date Wages/Other Compensations are to be paid to employees:

The City of Owensboro assesses a withholding fee of 1.33% of the compensation paid to employees while they are
working within the city limits. Daviess County assesses a withholding fee of .35% of the compensation 
paid to employees while they are working in Daviess County, outside the corporate city limits of the City  
of Owensboro. It is the responsibility of each employer to withhold these fees and submit them on the required  periodic basis.   
For the first year after registration the withholdings for either jurisdiction will be remitted by the employer on a quarterly basis. 
The employer will be notified of any change from the quarterly filing status. Forms for submitting the employee
withholdings will be mailed to the employer well in advance of the applicable due dates. If you wish to have the
withholding forms sent to an address other than that listed in Item No. 2 on page 1 of this application, please indicate below:

NAME

ADDRESS

9. BUSINESS ACTIVITY

Business Activity within the City of Owensboro or Daviess County occurs when a business generates sales revenue or
receipts from the sale, lease, or rental of goods, services or property within either jurisdiction and/or is paying compensation 
to employees working within the jurisdiction(s). NOTE:  Sales revenues or receipts generated within the corporate city limits 
of Owensboro constitutes business activity in the City of Owensboro. Sales revenues or receipts generated in Daviess  
County, outside the corporate city limits of Owensboro, constitutes business activity in Daviess County.

A.) Will you or have you conducted business activity in the City of Owensboro:  ______ YES  ______ NO
B.) Indicate the date business activity began or will begin in the City of Owensboro: _____/_____/_____
C.) Will you or have you conducted business activity in Daviess County: ______ YES  ______ NO
D.) Indicate the date business activity began or will begin in Daviess County: ____/____/____
E.) Is Business in Owensboro/Daviess County to be:  ______Permanent ______  Temporary
If temporary, give approximate dates of activity :                                    to
F.) Is business classified as non-profit for federal tax purposes:   __________ YES     ___________ NO

10. TYPE OF BUSINESS ACTIVITY

A. Check appropriate business classification:

         Agriculture, Forestry, Fishing                Wholesale Trade
         Mining                                        Retail Trade
         Construction                                  Insurance & Real Estate
         Transportation & Public Utilities             Manufacturing
         Services                                      Public Administration

B. Give brief description of primary business activity:

11. AMOUNT OF LICENSE FEE DUE WITH THIS APPLICATION

The City of Owensboro requires the payment of a $47 minimum license fee with this application, unless being filed by a non-profit  
organization or by an applicant under 18 years of age. Daviess County requires no payment with this application. If you answered   
Yes to question A in Section 9, unless exempt as described above, submit $47 with the application. If you answered No to question  
A in Section 9 no payment is required to be made with the application. MAKE CHECK PAYABLE TO: OCCUPATIONAL TAX 
ADMINISTRATOR if payment is required. MAIL TO: Occupational Tax Administrator
                                                                                                  PO Box 10008
                                                                                                 Owensboro, KY 42302

12. BUSINESS LOCATION INFORMATION

A.) Proposed Use of Location:

B.) Existing Use of Location:

C.) Approximate Building Area Size:

D.) Total Number of Off-street Parking Spaces:

E.) Are major alterations planned:            YES                                                             NO        If yes, give brief
explanation:

 F.) Is the applicant the owner of the premises to be licensed? ______ YES   _______ NO  If the answer is no give:    

NAME (Premise Owner)                          Address

DENIAL TO DELINQUENT TAXPAYERS
NO LICENSE WILL BE ISSUED TO ANY BUSINESS WHICH OWES THE CITY OF OWENSBORO OR DAVIESS COUNTY ANY 
DELINQUENT REAL ESTATE OR TANGIBLE TAXES OR ANY OCCUPATIONAL OR PAYROLL WITHHOLDING 
LICENSE FEES OR ANY OTHER FEE, TAXES, OR ASSESSMENTS OF ANY KIND.

            I hereby certify all information and statements herein are true and correct.

            SIGNED   x                                                                                              Date

                             Print Name

                     Official Title
                                       (Owner, Partner, Member, Treasurer, Agents, Etc.)

13. CITY OF OWENSBORO BUSINESS LOCATION APPROVAL
If your business is located in the City of Owensboro your business location must be inspected and approved  
by the following department.  

x
      Planning & Zoning Administrator/Building Inspector (270) 687-8656

COMMENTS: