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1. BUSINESS NAME: 2. BUSINESS MAILING ADDRESS: 3. BUSINESS LOCATION ADDRESS: 4. TELEPHONE 5. NAME, TITLE, AND ADDRESS OF OWNER & APPLICANT: OWNER NAME: HOME ADDRESS: CITY, STATE, ZIP: MAILING ADDRESS: CITY, STATE, ZIP: TELEPHONE APPLICANT NAME/TITLE: HOME ADDRESS: CITY, STATE, ZIP: MAILING ADDRESS: CITY, STATE, ZIP: TELEPHONE 6. DESCRIBE TYPE OF BUSINESS: MORGAN COUNTY PLANNING AND DEVELOPMENT Post Office Box 1357 150 East Washington Street, Suite 200 Madison, Georgia 30650 (706) 342-4373 Office (706) 343-6455 Fax New Business: Return application and notarized affidavit Renewal: Return application & notarized affidavit before December 31st Return to: Morgan County Planning and Development 150 E. Washington Street, Suite 200, Madison, Georgia 30650 OFFICE USE ONLY Zoning License # Tax Map and Parcel Amount Paid $ Payment type Issued by: Date NAICS CODE Occupational Tax Application 14. I certify that the all information given, including the figures given as a basis for taxation, is true and correct to the best of my knowledge, and that records shall be made available for inspection, as specified in Sec. 66-29 of the Morgan County Code. I understand that the issuance of an Occupation Tax Certificate does not indicate conformity with Morgan County Ordinances and it is my responsibility to conform with all ordinances. Morgan County expressly reserves the right to enforce any and all ordinances, regardless of payment. Signature Title Date • COMPLETE APPLICATION MUST BE RETURNED IN PERSON. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. • PHOTO ID PROVIDED MUST MATCH APPLICANT NAME. • PAYMENT AND AFFIDAVIT MUST ACCOMPANYAPPLICATION. MAKE CHECK PAYABLE TO: MORGAN COUNTY Thank you for doing business in Morgan County! 8. TYPE OF BUSINESS HOME OFFICE COMMERCIAL LOCATION INDUSTRIAL LOCATION 9. TYPE OF OWNERSHIP SOLE OWNER CORPORATION PARTNERSHIP LLC 10. TYPE OF REGISTRATION NEW DATE BUSINESS OPENED RENEWAL OUT OF BUSINESS CLOSED DATE 11. FEDERAL TAX I.D. OR SOCIAL SECURITY#: 12. STATE LICENSE # (IF APPLICABLE): 13. STATE SALES TAX # (IF APPLICABLE): 14. STATE USE TAX # (IF APPLICABLE): $ 7. OCCUPATIONAL TAX INVOICE (cash or check only) Your occupational Tax is based on the following: Administrative fee $40.00 Business owner $10.00 Employees X $10 $ Total due: ---PAGE BREAK--- Applicant: Name of Establishment: Establishment Address: By executing this affidavit under oath, as an applicant for an Occupation Tax Certificate, as referenced in O.C.G.A. § 50-36-1, from the Morgan County Board of Commissioners, the undersigned applicant verifies one of the following with respect to my application for a public benefit: I am a United States citizen. I am a legal permanent resident of the United States. I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency. My alien number issued by the Department of Homeland Security or other federal immigration agency is: The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit. 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 O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute. This document was executed in Madison, Georgia. Signature of Applicant Printed Name of Applicant SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF NOTARY PUBLIC My Commission Expires: Georgia Security and Immigration Compliance Act Applicant Benefit Affidavit Georgia Security and Immigration Compliance Act Applicant Benefit Affidavit Official Use Only The secure and verifiable document provided with this affidavit can best be classified as: U.S. Passport U.S. Passport Card U.S Military ID U.S Driver’s License* Tribal ID Card U.S. Permanent Resident Card Alien Registration Card Foreign Gov. Passport Employment Authorization Card Merchant Mariner Card Free & Secure Trade Card Nexus Card SENTRI Card Canadian Driver’s License Certificate of Citizenship Certificate of Naturalization Matricula Consular ID Copy of Document Attached *Note: A driver’s license from Alaska, Idaho, Illinois, New Jersey, New Mexico, New York, Rhode Island, Utah and Washington is not a verifiable document. Maryland and Massachusetts are pending. Verified By: Date: