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Registration# This form should be returned to: Occupational Tax Department 8700 Hospital Dr., 1ST Floor Douglasville, GA 30134 Your Occupational Tax Registration (business license) is due 12/31/2019 1 - - 50,000 95.00 95.00 95.00 2 50,001 - 99,999 101.00 103.00 105.00 3 100,000 - 249,999 128.00 140.00 153.00 4 250,000 - 499,999 180.00 212.00 245.00 5 500,000 - 749,999 232.00 284.00 337.00 6 750,000 - 999,999 310.00 392.00 475.00 7 1,000,000 - 1,499,999 359.00 479.00 599.00 8 1,500,000 - 1,999,999 469.00 639.00 809.00 9 2,000,000 - 2,499,999 579.00 799.00 1,019.00 10 2,500,000 - 2,999,999 635.00 905.00 1,175.00 11 3,000,000 - 4,999,999 806.00 1,201.00 1,596.00 12 5,000,000 - 6,999,999 1,166.00 1,761.00 2,356.00 13 7,000,000 - 9,999,999 1,706.00 2,601.00 3,496.00 14 10,000,000 - 12,999,999 2,007.00 3,202.00 4,397.00 15 13,000,000 - 15,999,999 2,188.00 3,683.00 5,178.00 16 16,000,000 - 18,999,999 2,249.00 4,044.00 5,839.00 17 19,000,000 - & up 2,490.00 4,885.00 7,280.00 OFFICE ONLY Registration # Tax Class NAICS Paid By AMOUNT BY: Ck # CC CASH DOUGLAS COUNTY OCCUPATIONAL TAX BUSINESS LICENSE RENEWAL FORM 8700 Hospital Drive, Douglasville, Georgia 30134 [PHONE REDACTED] or [PHONE REDACTED] *BUSINESS LICENSE ARE RENEWABLE YEARLY AND EXPIRE ON 12/31 EVERY YEAR* Bracket Gross Receipts Tax Class 1 Tax Class 2 Tax Class 3 In accordance with the Occupation Tax ordinance, County of Douglas Georgia I, the undersigned, certify that I am the person duly authorized by the business herein named to file this return, including the accompanying schedules and statements and that the same are true, correct and complete. Applicant Signature Title Date PLEASE LIST ANY CHANGES: EMAIL ADDRESS: NON-U.S. CITIZENS MUST PRESENT IMMIGRATION CARD & I.D. PRIOR TO RECEIVING NEW REGISTRATION. Please complete the Affidavit of Exemption form if you have UNDER 11 EMPLOYEES: EXEMPT [ ] must be notarized If you have over 10 employees you must e-verify! OVER 10 EMPLOYEES PLEASE LIST YOUR EVERIFY# [ ] RENEWAL [ ] CLOSING [ ] DATE CLOSED: / / YEARLY GROSS RECEIPTS $