CLEAR FORM                    PRINT
                     PULASKI COUNTY GOVERNMENT -
                     DIVISION OF OCCUPATIONAL TAX
                     MAIN STREET  P O BOX 658
                     SOMERSET, KY 42502-0658
                     (606) 679-2393  FAX 1(877) 655-7154

Every business or individual subject to the Occupational License Fee is required to complete this application and return it to the Tax Administrator.  (OAG-
85-1) Kentucky Attorney General states that the Occupational Tax Office must let persons inspect records pertaining to principal business location, address
and telephone number of each person or entity(trade name-if different)and nature of business of the person or entity filing the application.  Answer all
applicable questions:
FOR BUSINESS USE ONLY:
Name of business or trade name:___________________________________________________________________________ 
Business Street Address 
(Pulaski County Address)_________________________________________________________________________________

City, State, Zip:_________________________________________________________________________________________

Mailing Address_________________________________________________________________________________________
(To receive quarterly and annual forms)
City, State, Zip:_________________________________________________________________________________________

Telephone number:  (______)______________________________________Fax number: (_______)____________________

Date operations started in Pulaski County:_________________________ Approximate Number of Employees___________

Nature of Business:_______________________________________________________________________________________

Type of Business:_______Corporation_____S Corporation______Partnership______Individual_____Fiduciary_____Farm

______LLC  _____Religious or Non-Profit Organization ______Proprietorship_____Other (Please specify)____________

Federal Tax I.D.#_________________Accounting period: ____Calendar year(December 31st) ____Fiscal year (month___)

List previous owner's name and address:____________________________________________________________________

List contact person(s)name(s)_______________________________________telephone#______________________________

INDIVIDUAL USE ONLY:  (FOR THOSE PERSONS WHOSE EMPLOYER DOES NOT WITHHOLD QUARTERLY TAXES:
FEDERAL EMPLOYEES INCLUDING UNITED STATES POSTAL SERVICE)

Name:_______________________________________________Address____________________________________________

City, State, Zip:_________________________________________________________________________________________

Federal Agency/Business for which you work and address:_____________________________________________________

Start date                                                                                       Social Security #___________________________________

Telephone number (Agency) (______)_______________________________(Home) (_______)________________________

CONTRACTORS:  List All Subcontractors Working under You on this or any Job in Pulaski County.
PARTNERSHIPS:  List All Partners with Address and Social Security Information.  (Use additional sheet if necessary)

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it
is true, correct and complete.

Signature                                                Title             Date_____________
FORM APPL

                                                                                             01072016