City of Danville
                                             OFFICE OF
                                             COMMISSIONER OF THE  REVENUE
                                                                                                                                                                         
                  James M Gillie                                              311 MEMORIAL DRIVE
                  COMMISSIONER               NEW BUSINESS LICENSE FORM                                                                                                   PO BOX 480
                                                                              DANVILLE, VIRGINIA  24543
                                                                                                                                                                         (434) 799-5145
                                                                              (434) 799-5148 Fax
TRADE NAME__________________________________________________________________________________________

FED TAX ID OR SS #_________________________ESTIMATED GROSS UNTIL YEAR END______________________

MAILING ADDRESS____________________________________________________________________________________

LOCAL BUSINESS ADDRESS____________________________________________________________________________

LOCAL BUSINESS PHONE #______________________  EMAIL_______________________________________________

NATURE Of BUSINESS__________________________________________________________________________________

CONTACT PERSON__________________________TITLE______________________PHONE#______________________

CHECK APPLICABLE                  AND SUPPLY INFORMATION RELATING TO OWNERSHIP

____INDIVIDUAL NAME_________________________________________SS#___________________________________

        HOME ADDRESS___________________________________________________________________________________

                                       ____________________________________________PHONE #_______________________________

____PARTNERSHIP NAME (1)____________________________________SS#___________________________________

        HOME ADDRESS___________________________________________________________________________________

                                      ____________________________________________PHONE #________________________________

                                   NAME (2)_____________________________________SS #____________________________________

         HOME ADDRESS___________________________________________________________________________________

                                       ____________________________________________PHONE #_______________________________

____CORP OR LLC NAME______________________________________________________________________

        ADDRESS OF CORP. OFFICE________________________________________________________________________

        PHONE # OF CORP. OFFICE_________________________________________________________________________

CONTRACTORS (PROVIDE STATE LICENSE #)

CLASS A #_________________________CLASS B #_________________________CLASS C #________________________

TYPE OF CONTRACTOR________________________________________________________________________________

BEGINNING DATE OF BUSINESS IN DANVILLE__________________________________

SIGNATURE________________________________DATE______________(PARTNER)_____________________________