Jefferson Parish Sheriff’s Office 
                                                                                     Bureau of Revenue and Taxation 
JOSEPH P. LOPINTO, III                                                               P.O. Box 248 
Sheriff and Ex-Officio Tax Collector                                                 Gretna, LA 70054-0248 
Parish of Jefferson                                                                  Voice: (504) 376-2459 
                                                                                     Fax: (504) 376-2469
                                                                                      
1. Date of application            /        / 

2.Application For:                     A.     Sales/Use Tax                  B.      Occupational License Tax 
                                       C.     Chain Store Tax                D.      General Registration 

3.Reason for applying:                 A.     Started new business           C.      Other (specify): 
                                       B.     Purchased ongoing business:            Name of previous owner: 
Have you ever registered with this office?       Yes    No                   If yes, list below the business name. 
Business name:                                                                                        If closed, enter date closed:     /          / 

4.Federal Employer ID Number             None          5.LA Sales Tax Number           None            6.Local Tax Number                      None 

7.A. Taxpayer Name/Corporate Name:
 B. Trade name of business:                                                                                      Telephone: (       ) 

8.A. Business address (NO P.O. Box or General Delivery):
  City:                                                               State:                                     Zip Code:                     - 
 B. Address for receiving tax forms/correspondence: 
   City:                                                              State:                                     Zip Code:                     - 
 C. Website:                                                          D. Location of accounting records: Check one as noted in      8 A        8 B 
                                                                      If other, list complete address below. 

9.Type of organization:                Sole Proprietor        Partnership            Corporation             LLC            LLP                LP 
                                       Governmental           Nonprofit (IRS Ruling must be attached)        Other: 

10.If sole owner/individual: Name:                                                                               Last 4-Digits of SSN: xxx-xx- 
 (Attach copy of valid photo I.D.)
 Home address:                                                                                                   Telephone: (       ) 
 City:                                                                State:                                     Zip Code:                     - 

11.    If corporation, LLC, LLP, LP or Name:                                    Title:                           Last 4-Digits of SSN: xxx-xx- 
 partnership: name, title, Social 
  Security Number, home                Address:                                                                  Telephone: (       ) 
    address and telephone number       Name:                                    Title:                           Last 4-Digits of SSN: xxx-xx- 
 of officers, members, 
  managers or partners ,               Address:                                                                  Telephone: (       ) 
    attach additional sheets if        Name:                                    Title:                           Last 4-Digits of SSN: xxx-xx- 
 necessary to complete this 
  information.                         Address:                                                                  Telephone: (       ) 

12.Tax Contact Person:                                                                                           Title: 
 Telephone: (           )                              Email address: 

13.Agent for service of process: Name:                                                                           Telephone: (       ) 
 Physical Address:
 City:                                                                State:                                     Zip Code:                     - 

14.Date business started/acquired at                   15.Number of other business locations                 16.Number of retail business locations
 this location:           /            /                in Jefferson Parish?                                  nationwide? (Incl. this location)

17.A. Description of business activity:

B. NAICS Code:                               C. Food/Beverage Sales:    Yes  No      D. Firearm Sales:       Yes No     E. Tobacco Products:       Yes No 

I affirm that the 
 Information   given on   Signature of applicant:                                                                Title: 
this application is 
 true   and correct.      Signature of preparer:                                                                 Date: 
                                       PLEASE REFER TO INSTRUCTIONS - INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED 

                                     OCCUPATIONAL LICENSE SCHEDULE "A" 
                                            Check and complete only one of 18 through 21 

18. Business opened within prior 30 days               nd                     st
           A.  Business opened between December 2  and December 31  
                 Gross receipts for the remainder of calendar year: $ 
                 Locate tax due from application rate table and enter on line 22 below. 
                                                                              nd                  st
           B.  Business opened less than 30 days (excl. period December 2  to December 31 ) 
                 The tax due will be the minimum of applicable rate table. Enter on line 22 below.

19. Business opened more than 30 days
         Gross receipts for first 30 days: $
         Less deductions (describe):                                                     $                     equals $             which 
         multiplied by the number of months, or major fraction thereof, remaining in the year        amount to a tax basis of $           . 
         Locate tax due from applicable rate table and enter on line 22 below.

20. Business opened during previous calendar year
         Gross sales for remainder of calendar year: $
         Less deductions (describe):                                             $                   equals $                 which 
         divided by the number of days in operation        which multiplied by 365 amounts to a tax basis of $                  . 
         Locate tax due from applicable rate table and enter on line 22 below.

                                                    st
21. Business opened on or prior to January 1  of the previous year
         Gross sales for the calendar year: $
         Less deductions (describe):                                             $                   equals a tax basis of $              . 
         Locate tax due from applicable rate table and enter on line 22 below.

22.LICENSE FEE/RATE BASED ON TABLE #                  ……………………………………………………………………$ 
23.To be used by those occupations paying a fee based on units, indicate number of seats, spaces, pool tables,etc. 

                 Item                               Number                   Fee Per Item           Total For This Item 

                                                                      TOTAL BASED ON UNITS……………….$ 
24.Chain store tax due (as calculated from chain store tax schedule on page 8)……………………………………… $
25.Amount of tax due (add lines 22, 23, and 24)……………………………………………………………………………$
26.Penalty……………………………………………………………………………………………………………………….. $
27.Interest……………………………………………………………………………………………………………………….. $
28.Total amount due……………………………………………………………………………………………………………$

                                                      FOR OFFICE USE ONLY 
If located in unincorporated Jefferson Parish, is zoning clearance attached?    Yes     No                    Account #: 
In compliance with trade name recordation requirement?    Yes         No (If no, amend trade name accordingly)
                                                                                                              License Yr.: 
This business will be coded for the following: 
      Sales/Use Tax           Hotel/Motel Tax                                                                 License Code: 
      Food/Drug Tax           Occupational License Tax 
      Alcohol Beverage Permit Chain Store Tax                                                                 Delq. Date: 
      Occupancy Tax           Other: 
                                                                                                              Record Type: 
Account Classification: 
      Regular                 Vehicles for Hire                       Temporary Vendor                        NAICS Code: 
      Non-Profit              Other Exempt: 
                                                                                                              Registration Method: 

Processed By:                                                           Reviewed By: