YOU MUST FIRST COMPLETE A ZONING APPLICATION
(CERTIFICATE OF NO TAX DUE FORM IS REQUIRED- WHEN APPLICABLE)

BUSINESS NAME:*

ARE YOU THE PROPERTY OWNER?*

YES	NO (IF NO PROVIDE COPY OF LEASE

PROPERTY OWNERS CONTACT INFORMATION (IF YOU DO NOT OWN THE PROPERTY)

OWNERSHIP:*

CORPORATION LLC PARTNERSHIP

SOLE PROPRIETOR TRUST

PLEASE CHECK ONE*

NEW RENEWAL CHANGE OF OWNER

CHANGE OF ADDRESS BUSINESS NAME CHANGE

PLEASE CHECK ONE

SERVICE

MANUFACTURE

LIQUOR LICENSE INFORMATION - CHECK ALL THAT APPLY

RESTAURANT/BAR WEEKDAY/SATURDAY SALES

WEEKDAY/SATURDAY/SUNDAY SALES PACKAGE SALES

LIST VENDING MACHINES

LIST VENDORS

LIST ALL LICENSES AND CERTIFICATIONS THAT ARE REQUIRED FOR OUR BUSINESS
(ATTACH COPIES)*

BUSINESS OWNER(S)

NAME:*

TITLE

HOME ADDRESS:*

CITY, STATE, ZIP*

MAILING ADDRESS (IF DIFFERENT)

CITY, STATE, ZIP

EMAIL ADDRESS*

CONTACT NUMBER*

NAME:

TITLE

HOME ADDRESS:

CITY, STATE, ZIP

MAILING ADDRESS IF DIFFERENT

CITY, STATE, ZIP

EMAIL ADDRESS

CONTACT NUMBER

BUSINESS ADDRESS

ADDRESS:*

CITY, STATE, ZIP*

MAILING ADDRESS IF DIFFERENT

BUSINESS PHONE:*

EMAIL:*

HOURS/DAYS OF OPERATION:*

EMERGENCY CONTACT INFORMATION

NAME*

CONTACT NUMBER*

ADDRESS*

CITY, STATE, ZIP*

IF YOU RENT A BOOTH AT A BARBER OR BEAUTY SHOP, YOU MUST ALSO COMPLETE THIS SECTION

BEAUTY/BARBER SHOP BUSINESS NAME:

ADDRESS:

OWNER NAME AND PHONE:

ALARM COMPANY IF APPLICABLE

ADDRESS:

PHONE:

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SIGNATURE OF APPLICANT*

DATE*

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I CERTIFY THAT I HAVE OBTAINED ANY AND ALL CONSENTS, AUTHORIZATIONS, VARIANCES, WAIVERS, LICENSES, PERMITS AND APPROVALS FROM ANY FEDERAL, STATE, COUNTY, MUNICIPAL OR OTHER GOVERNMENTAL OR QUASI-GOVERNMENTAL AGENCY, DEPARTMENT, BOARD, COMMISSION BUREAU OR OTHER ENTITY OR THIRD PARTY NECESSARY FOR THE OPERATION OF MY BUSINESS IN COMPLIANCE WITH ALL APPLICABLE FEDERAL, STATE AND CITY LAWS AND REGULATIONS, AND THAT I WILL OPERATE MY BUSINESS IN ACCORDANCE THEREWITH. I FURTHER UNDERSTAND THAT ANY FALSE STATEMENTS MADE ABOVE ARE GROUNDS FOR DENIAL, SUSPENSION OR REVOCATION OF THE BUSINESS LICENSE.

IF ADDITIONAL DOCUMENTS ARE REQUIRED PLEASE EMAIL THOSE TO CITYCLERK@CITYOFBLACKJACK.COM

FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS AREA

INSPECTION DATE

INSPECTOR'S REPORT

INSPECTOR'S SIGNATURE

BUSINESS LICENSE #

LICENSE EFFECTIVE DATE