Do you need reasonable accommodation to complete this form?  If so, please call 256-772-5654

APPLICATION TYPE:                                                                                                       Date ________________ 
    Business License                         City of Madison                                                            ID__________________ 
    Tax Account                        Business License & Tax Application                                               Payment_____________ 
    Location Change                 P.O. Box 99  ●  Madison, Alabama 35758                                              Amount______________ 
    Name Change                Phone 256-772-5654 ● Fax 866-591-8740
                                              revenue@madisonal.gov 
    Owner Change

PLEASE PRINT OR TYPE 

Legal Business Name:________________________________________________                ____ EIN, State ID, or SS  #__________________ 

D.B.A. (if different from above): ________________________________________________________________________________

Mailing Address:_______________________________________________________________________________________                             ______
                        street                                city                         state              zip code

Physical Address:_______________________________________________________________________________________ street city state zip code _____ 
                
Email  Address__: ____________________________________________________________________________________________ 

                                                                   FAX                     (_______)__________________________ 
Telephone:(_______)________________________(___  ____)_______________________
                               WORK                                                                           HOME/CELL
Name/Phone Contact Person:_____________________________________________________________________________                             ______ 

Names of Owner(s), Partner(s), or Officer(s) – Use back or attach separate sheet if necessary: 

_________
    NAME __________________________________________________________________________________TITLE SOCIAL SECURITY NUMBER __________________ PHONE
__________________________________________________________________________________________ ________________ _
    NAME                               TITLE                       SOCIAL SECURITY NUMBER                                PHONE 

Description of Work:____________________________________________________________________________________                            ______ 
Number of Employees  :____________________________________________________________________________________                            ____ 
Organization Type:       Corporation           LLC                 Partnership                   Sole Proprietor 
                                                                                           License amount   $ _____________
Estimated gross receipts: $ ________________________________________ 
                                                                                                      Issue Fee: $ 12.00
                                                                                           Total amount due$___________             ___ 

CONTRACTOR INFO:
Date work begins________ _______________________________ Contract Amount $ ________        ______________________________________ 
Job Location________________________    __________________________________________________________________________________ 
If Sub, Name of General Contractor___  ____________________________________________________________________________________ 

   This Application has been examined by me and is to the best of my knowledge a true and complete representation of the above 
   named entity and person(s) listed. 

   Signature of Applicant ___________________________________________________________________________________ 

   Title __________________________________________________________ Date ___________________________________ 

                               NAICS Code(s) _______________________________________________ 

                        Tax:  Sales     Use   Rental    Lodging    Liquor    Tobacco    Gas 

                               Filing:  Monthly  Quarterly        Occasional  Other 

                                                              SUBMIT