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: $ 14.00
                                                                                             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