Jefferson Parish Sheriff’s Office
NEWELL NORMAND                                                                             Bureau of Revenue and Taxation
Sheriff and Ex-Officio Tax Collector                                                       P.O. Box 248                     9500F
Parish of Jefferson                                                                        Gretna, LA 70054
                                                                                           Voice: (504) 376-2459
1. Date of application ________/________/________                                          Fax: (504) 376-2469
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  ❏ 8A   ❏ 8B
                                                                                                         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: ______________________________________________________________ SSN: _________________________________
(Attach copy of valid photo I.D.)
Home address: ____________________________________________________________________ Telephone: ( _____ ) _______________________
City: _____________________________________________________________ State: ____________ Zip Code: __________________–___________

11. If corporation, LLC, LLP,      Name                                              Title                      SSN: _____________________________
LP or partnership: name,
title, Social Security             Address                                                                      Telephone: ( ____ ) __________________
Number, home address
and telephone number of            Name                                              Title                      SSN: _____________________________
officers, members, man-
agers or partners                  Address                                                                      Telephone: ( ____ ) __________________
Attach additional sheets 
if necessary to complete           Name                                              Title                      SSN: _____________________________
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. Emergency Contact Person: ______________________________________________________________  Telephone: ( _____ ) ______________________
15. Date business started/acquired at                   16. Number of other business locations             17. Number of retail business locations
this location: _______/_______/_______                     in Jefferson Parish? ______________                nationwide? (incl. this location) ____________
18. A.  Description of business activity: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
B.  NAICS Code: _____________________________________      C.  Food/Beverage Sales:  ❏ Yes    ❏ No           D.  Firearm Sales:  ❏ Yes    ❏ No
I affirm that the information
given on this application is
true and correct.            Signature of applicant: _______________________________________________________ Title: ___________________________________
I request the Emergency
Contact telephone number     Signature of preparer: _______________________________________________________ Date: ___________________________________
be kept confidential.
                             PLEASE REFER TO INSTRUCTIONS – INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

                          OCCUPATIONAL LICENSE SCHEDULE “A”
                                   Check and complete only one of 18 through 21                            9500B

❏ 18. Business opened within prior 30 days
             A.   Business opened between December 2nd and December 31st
                Gross receipts for the remainder of calendar year: $ ______________
                Locate tax due from applicable rate table and enter on line 22 below.

             B.   Business opened less than 30 days (excl. period December 2nd to December 31st)
                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.

❏ 21. Business opened on or prior to January 1st 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.
                                                          Fee                 Total For
                Item               Number               Per Item              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                                                       Delq. Date: _____________________
❏ Alcohol Beverage Permit ❏ Chain Store Tax
❏ Occupancy Tax           ❏ Other: __________________________________________                              Record Type: ___________________
                                                                                                           NAICS Code: ___________________
Account Classification:
❏ Regular                 ❏ Vehicles for Hire             ❏ Temporary Vendor                               Registration Method: _____________
❏ Non-Profit              ❏ Other Exempt: ___________________________________
Processed By: __________________________________________     Reviewed By: __________________________________________