Bbl Ez Form – Fill Out and Use This PDF

D E P A R T M E N T O F C O N S U M E R & R E G U L A T O R Y A F F A I R S
BBL EZ-FORM					BASIC BUSINESS LICENSE
								DCRA USE ONLY
					APPLICATION FORM 2009-01			CUSTOMER NO.
LANGUAGE PREFERRED				English	Spanish	Chinese	Vietnamese		Amharic	Korean	Other: ____________
BUSINESS TYPE
Sole Proprietor		Partnership		Limited Liability Co.		Corporation (For Proit)			Corporation (Non- Proit)
SECTION A	APPLICANT/BUSINESS INFORMATION
1a. BUSINESS OWNER __________________________________________________________________________
If owner is Sole Proprietor, print his/her name. If owner is Corporation, Limited Liability Company (LLC), or Partnership, print oficial Company Name to be licensed
2a. FEDERAL ID		Federal Employee IdentiFIcation Number ________________ or Social Security Number									_____-___-_______
3a. TRADE NAME (if applicable)			______________________________________ 4a. Number of Employees ____________________
	BUSINESS ADDRESS INFORMATION
	If this is a Corporation, LLC or Partnership, please provide address of the company’s main headquarters or main mailing address here.
5a. STREET ADDRESS _________________________________________ SUITE or APARTMENT NUMBER __________
CITY ____________________			STATE _____________ ZIP CODE				________________________
PHONE NUMBER (		) ________-_______________ 6a. EMAIL ___________________@_______________________

SECTION A2 OFFICERS, PARTNERS, MEMBERS

All Corporations, Partnerships, LLCs, and Unincorporated Associations must complete this section

7a. PRESIDENT/PARTNER/MEMBER NAME First ________________________ Last ______________________ Init ______

STREET ADDRESS _________________________________________ SUITE or APARTMENT NUMBER __________

CITY ____________________ STATE _____________ ZIP CODE ________________________

8a. VICE PRESIDENT/PARTNER/MEMBER First _________________________ Last ______________________ Init _______

STREET ADDRESS _________________________________________ SUITE or APARTMENT NUMBER __________

CITY ____________________ STATE _____________ ZIP CODE ________________________

9a. SECRETARY/TREASURER/PARTNER/MEMBER First ________________________ Last _______________ Init ______

STREET ADDRESS ____________________________________________________ SUITE or APARTMENT NUMBER __________

CITY ____________________ STATE _____________ ZIP CODE ________________________

SECTION B PREMISE ADDRESS INFORMATION

Location of business operation to be licensed

1b. STREET ADDRESS _________________________________________ SUITE or APARTMENT NUMBER __________

CITY ____________________	STATE _____________ ZIP CODE ________________________
2b. QUADRANT (if known) NW	NE SW SE 3b. Ward ____

PHONE NUMBER (

) ________-_______________ EMAIL ___________________@__________________

CERTIFICATE OF OCCUPANCY/HOME OCCUPANCY PERMIT INFORMATION

4b. CERTIFICATE OF OCCUPANCY/HOME OCCUPANCY NUMBER _________________ DATE ISSUED ______________

SECTION C BILLING ADDRESS INFORMATION

1c. BUSINESS NAME _________________________________ ATTENTION ______________________________

(if different than line 1a.)

STREET ADDRESS _________________________________________ SUITE or APARTMENT NUMBER __________

CITY ____________________ STATE _____________ ZIP CODE ________________________

SECTION D WEIGHTS & MEASURES

If you have electronic price scanners or weight measurement devices, contact the Ofice of Weights and Measures at 202-698-2130 to register your devices.

1d. DEVICES USED _________________________________ NUMBER OF DEVICES ______________________________

DCRA BBL HELP LINE 202-442-4400	dcra.dc.gov

Corporations, Partnerships and LLCs must provide Registered Agent information. Sole Proprietors who are not DC residents must name Resident Agent and provide written consent.

1e. NAME _________________________________ BUSINESS NAME ___________________________________

STREET ADDRESS _________________________________________ SUITE or APARTMENT NUMBER __________

CITY ____________________ STATE _____________ ZIP CODE ________________________

PHONE NUMBER (

) ________-_______________ EMAIL ___________________@__________________

I coNsent to act as a Resident Agent for the applicant on Line 1a.

Signature _________________________________________ Date

SECTION F			LICENSE ENDORSEMENT & BUSINESS ACTIVITIES
			Primary business category should be placed on line 1.
		BUSINESS ACTIVITY - LICENSE ENDORSEMENT		RELATED NAICS CODE
	1	PRIMARY BUSINESS ACTIVITY:				NUMBER OF SEATS:
	2
	3					NUMBER OF UNITS:
	4
	5
	6

SECTION G CLEAN HANDS SELF CERTIFICATION

TO THE APPLICANT: Please read this form carefully and completely before signing. The District government shall not issue or reissue any license or permit if the applicant owes more than $100.00 in outstanding debt to the District of Columbia.

I, __________________________, as ______________________________ , certify that _______________________________
(name)	(owner/partner/corporate oficer)	(business name)
trading as _____________________ at _________________________________, using business tax number ______________,
(trade name)	(business address)	(FEIN/SSN)

as of this date, does not owe more than one hundred dollars ($100.00) in outstanding debt, penalties and fees to the District of Columbia.

I understand that a signed and dated Clean Hands Self Certiication Form is required as documentation to accompany my application for a basic business license, license endorsements, and permits. I understand that by completing and submitting this form I am not guaranteed that my license or permit will be approved.

I understand that the Department of Consumer and Regulatory Affairs may conduct an investigation to ascertain the veracity of the information contained in this Clean Hands Self Certiication Form.

I understand that if I knowingly provide false information on this Clean Hands Self Certiication Form, the Department of Consumer and

Regulatory Affairs will proceed immediately to revoke each license or permit for which I am applying and ine me one thousand dollars
($1,000.00). ____________________________________ ________________________________
Signature and Title	FEIN/SSN	Date

I hereby submit this application, required forms and payment in the amount of $__________ for consideration of Basic Business License

based on the information in this application.

Applicant Signature ______________________________________________ Date

I/We understand that, anyone who makes a false statement on this form can be criminally prosecuted; and, if convicted, ined up to $1000,

imprisoned up to 180 days, or both, under D.C. Oficial Code § 22-2405.

DC INSPECTOR GENERAL HOTLINE: If you are aware of corruption, fraud, waste, abuse or mismanagement involving any DC government agency, oficial or program, Contact the Ofice of the Inspector General (OIG) at (202) 727-0267 or (800) 521-1639 (toll free). All reports are conidential and you may remain anonymous by law. Government employees are protected from reprisals or retaliation by their employers for reporting to the OIG. The information you provide may result in an investigation leading to administrative acion, civil penalties or criminal prosecution in appropriate cases.

NOTICE OF NON-DISCRIMINATION: In accordance with DC Human Rights Act of 1977, as amended, DC Code Section 2.1401.01 et seq., (“the Act”) the District of Columbia does not discriminate on the basis of race, color, national origin, sex, age, marital status, sexual orientation, family responsibilities, matriculation, political afiliation, disabilities, source of income, or place of residence or business. Discrimination in violation of this act will not be tolerated. Violators will be subject to disciplinary action.