OCCUPATIONAL LICENSING                              
                        
                                            “Good Land      Good Living      Good People”   
                                          419      Washington Street          Shelbyville, KY 40065  
                                                               (502) 633-7685                 
                                                                       
                                                   REGISTRATION FORM                                                                      
Please complete and return with $75 registration fee to 419 Washington Street, Shelbyville, KY 40065. Make checks 
payable to: “Shelby County Occupational License Fee Office”. Note: The following information is necessary for our 
records and will be held in strict confidence.      
  
1)  Business or trade name            ______________________________________________________________   
                                                  
          Business Owner             _____________________________________________________________   
       
2)  Local business address             ______________________________________________________________  
                          (No PO Boxes)            Street                                                    City                                        State             Zip Code  
   
3)  Mailing address for forms          ______________________________________________________________  
   4)  Email address (if applicable)         
   ______________________________________________________________                                
                                                   Street                                                    City                                        State             Zip Code  
       
5)  Telephone numbers                  Business   ________________________       Fax     ____________________                                                                        
       
6)  Social Security Number            _____________________________    Federal ID #   ____________________  
       
7)  Nature of Business                   
   _______________________________________________________________  
       
8)  Date business started in Shelby County          ___________/_____________/_____________  (Month/Day/Year)   
       
9)  Do you have employees working                    in         Shelby County?  If yes, how many?   ________               
       
                                                                        Simpsonville?     If yes, how many?   ________  
  
10) Do you have self-employed persons within your business?       ___________  
           (If YES attach a list indicating name(s) and location of current project(s).)  
  
11) Accounting period per federal income tax return                     Calendar year (12/31)  
   
                                                                                          Fiscal Year    _______/________ (Month/Day)    
  
12) Contact person name, address and telephone      _______________________________________________     
                                                             
                                                                    ___________________________________________________  

                                                                                                                              Street  
                                                                                                
      ____________________________________________                                                                                                    
                         City                               State   Zip Code                      Phone  
                                                                                                                                                   
 I certify to the best of my knowledge, the above information is true, accurate and complete.  
  
__________________________________      _______________________________________________     __________________  
          Signature                Print Name and Title (i.e. Owner, CEO, etc.)                                                             Date  
            Please indicate form of payment:         CHECK #_____________________                 CASH                                                          
                                                                                              
                                                                                                Rusty Newton  
                           Occupational License Fee Administrator  
                       Phone: (502) 633-7685     Fax: (502) 647-0449    rusty.newton@shelbycoky.com  
                           Monday - Friday 8:30 am - 4:30 pm