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GORDON COUNTY, GEORGIA APPLICATION FOR BUSINESS LICENSE Please print Date of 1. Name of Owner: Home Address: Social Security Number: Phone number (include area code) 2. Name of Company: Incorporated____________ Proprietorship_____________ Partnership_____________ Service Address: Mailing Address: Daytime Phone number: Contact Person: 3. Name of President and Financial Officer: Nature of Business: Tax I.D. # 4. Will work be performed on site? Yes No If yes, what type of work? If yes, will the public be visiting this site to conduct business? Yes No Sales Tax I.D. # (If Applicable) NAICS Code # The refusal to provide the information above shall be provided to the Georgia Department of Revenue. The failure or refusal of such person to provide such information shall not toll or extend the time of payment established for such occupation tax or regulatory fee under Code Section 48-13-20. 6. Number of employees: Federal Work Authorization User ID # (E-Verify) 7. Number of Locations for this business: Date Business began at this location: 8. Map/Parcel # of business location (available from Tax Assessor’s Office): 9. Current zoning of property (available from Building, Planning & Development Office): Property conforms to zoning regulations? Yes Signature of Building, Planning & Development Office representative required: 10. Is food being prepared for resale or effecting septic system? Yes If yes, signature of Environmental Health representative required: 12. Is the business a commercial establishment? If yes, signature of Fire Inspector required: 13. Does the company own the building and real estate? if no, list the owner and his/her telephone Number: THIS DOES NOT SUPERCEDE ANY OTHER ORDINANCES OF GORDON COUNTY. PLEASE CONTACT THE APPROPRIATE OFFICES (i.e. Environmental Health, Fire Inspector, and Zoning Department) OR OTHER STATE AGENCIES. Building, Planning & Development: [PHONE REDACTED] Fire Inspector: [PHONE REDACTED] Tax Assessor: [PHONE REDACTED] Environmental Health Services: [PHONE REDACTED] Signature Date ---PAGE BREAK--- GORDON COUNTY BOARD OF COMMISSIONERS AFFADAVIT VERIFYING STATUS FOR COUNTY BENEFIT APPLICATION By executing this affidavit under oath, as an applicant for the Gordon County Board of Commissioners, Georgia Business License or Occupation Tax certificate, Alcohol License, or other public benefit as referenced in O.C.G.A. Section 50-36-1, I am stating the following with respect to my application for the Gordon County Board of Commissioners, Georgia Business License or Occupation Tax certificate, Alcohol License, or other public benefit (circle one) for (Name of natural person applying on behalf of individual, business, corporation, partnership, or other private entity) 1) I am a United States citizen OR 2) I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years or age or older and lawfully present in the United States.* In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of the Official Code of Georgia. Signature of Applicant: Date: Printed Name: Alien Registration number for non-citizens SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ____DAY OF 20___ Notary Public My Commission *Note: O.C.G.A. 50-36-1 requires that aliens under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number. Because legal permanent residents are included in the federal definition of “alien” , legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien registration number may supply another identifying number below: ---PAGE BREAK---