Legal Business Name

Name of Business in Pulaski County

Business Location Address in Pulaski County (must purchase a license for each location)

Mailing Address for License Renewal

Type of Business (please check one)

____ Retail

____ Wholesale

____ Service

Local Business Phone

Name of Person to Contact

Date Business Opened

Missouri State Sales Tax Number (required)

Nature of Business

I certify that the above information is correct.

___________________________________
Owner or Authorized Signature

_________________
Date

For Office Use Only

Date Received______________ License Mailed______________ Account #______________