TEL 919 856 5999 
                                                                                 FAX 919 743 4728 
                                                                                          
                    TAX ADMINISTRATION                                         Gross Receipts Tax Division 
                       www.WakeGov.com/tax                                      Wake County Justice Center 
                                                                              301 S. McDowell Street, Suite 3800  
                                                                               P.O. Box 2719  Raleigh, NC 27602 
  
                   PREPARED FOOD &  BEVERAGE  AX T CCOUNT A       PPLICATIONA    
                                              
 SELECT ONE:        Sole Proprietorship     Partnership           Corporation    L.L.C.  

  Other               (please specify)                                     
                                                                           
 OWNER/CORPORATION INFORMATION          : 
                                                                                                   
 Name:                                                  Telephone:    
                      
 Physical Address: 
                      
 Mailing Address: 
 E-mail Address:      

 INDIVIDUAL/CORPORATE OFFICER INFORMATION    :   (Residence Address/Telephone) 
                                                                                 
 Name:                                                   Home Telephone:   
                      
 Home Address: 
                      
 Mailing Address: 
                      
 E-mail Address: 

 BUSINESS INFORMATION: 
                      
 Trade Name: 
                      
 Location: 
                      
 Contact Name/Title 
                                                                                
 Contact Telephone:                                     Business Telephone: 
                                                                                 
 Federal Tax ID #:                                      Business Begin Date: 
 
                                          Wake County Tax Administration 
  Return completed application to:        Gross Receipts Division 
                                          P.O. Box 2719  Raleigh NC 27602