CITY OF OWENSBORO/DAVIESS COUNTY FISCAL COURT
                                 OCCUPATIONAL BUSINESS LICENSE APPLICATION
                                                     PO BOX 10008, OWENSBORO KY  42302
                      PHONE:  (270) 687-5600     FAX:  (270) 687-8526     www.owensboro.org

1. Check one                     New application                          Adding a city license to account #

2. Check where business is conducted:  Make check payable to "Occupational Tax Administrator"
                    $ 75  City of Owensboro                               $0  Daviess County
                    (Minimum Annual License Fee)
Every business or individual subject to the City of Owensboro/Daviess County, KY Occupational License Ordinance is required to complete  this
application and return it to the City of Owensboro.  WARNING:  Any false statement made herein shall be punishable according to law;
and may be cause for denial of the application or the revocation of the business license issued pursuant thereto.

3. Legal Name of Business or Applicant if Sole Proprietor:

4. Doing Business As or Trade Name (if applicable):

5. Brief description of business activity:

6.  Primary Business Address or Corporate Headquarters:                   7.  City of Owensboro/Daviess County Business location:
Contact Name                                                              Contact Name
Address                                                                   Address

City                             State               Zip                  City                  State            Zip
Telephone (       )                                                       Telephone (       )
Email                                                                     Email

8.  Mailing Address for Payroll Withholding Forms:                        9.  Mailing Address for Net Profit Return:
Contact Name                                                              Contact Name
Address                                                                   Address

City                             State               Zip                  City                  State            Zip
Telephone (       )                                                       Telephone (       )
Email                                                                     Email

10.Business Entity (Select One):                     Sole Proprietor      Partnership           Corporation
                                                     LLC - Individual     LLC - Partnership     Non Profit *
                                                     * NOTE:  Non Profit must attach 501 C(3) Determination Letter from Internal Revenue Service

11.KY Sales Tax No.                                                   12. KY Withholding Tax No.

13.Commonwealth Business Id No.

14.Federal ID No.                                        AND/OR       Social Security No.

15.Accounting Period:                                Calendar Year        Fiscal Year Ending

16.Date Business will begin in the City of Owensboro and/or Daviess County, KY

17.Is Business in the City of Owensboro and/or Daviess County to be:                            Permanent           Temporary

If temporary, give approximate dates of activity:

18.When did or will you first pay employees for working in the City of Owensboro and/or Daviess County
Withholding fee for City of Owensboro = 1.78%         Daviess County = 0.35%
              I have no employees working in the City of Owensboro and/or Daviess County, KY

19.Owner(s) of Officers of Business:

         NAME                       ADDRESS                      PHONE #        DOB                     SOCIAL SECURITY #

20.Is the applicant the owner of the premises to be licensed?               YES                       NO
         If you answered NO please complete information below.

Name (Premise Owner)                                             Address

                                    DENIAL TO DELINQUENT TAXPAYERS
NO LICENSE WILL BE ISSUED OR RENEWED TO ANY BUSINESS OR INDIVIDUAL WHICH OWES THE CITY OF OWENSBORO AND/OR 
DAVIESS COUNTY, KY 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.  ALL LICENSES ARE SUBJECT TO REVOCATION FOR 
VIOLATION OF THE OWENSBORO MUNICIPAL CODE.

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

SIGNATURE                                                                   Date

Print Name

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

                      PLANNING & ZONING ADMINISTRATOR/BUILDING INSPECTOR (270) 687-8665

APPROVAL                                                                    Date

COMMENTS:  

MAIL APPLICATION TO:                                          OR            DROP OFF AT:
         City of Owensboro                                                      City Hall
         PO Box 10008                                                           101 E 4th Street
         Owensboro, KY  42302                                                   Owensboro, KY

PLEASE MAKE CHECK PAYABLE TO:  OCCUPATIONAL TAX ADMINISTRATOR