Philadelphia Form 81 76 – Fill Out and Use This PDF

APPLICATION FOR ANNUAL

CITY OF PHILADELPHIA

Follow Instructions Below:

DEPARTMENT OF LICENSES AND INSPECTIONS

PHILADELPHIA

BUSINESS

CONCOURSE LEVEL • LICENSE ISSUANCE UNIT

For further information

PRIVILEGE LICENSE

1401 JOHN F. KENNEDY BLVD.

call 215-686-2463

PHILADELPHIA, PA 19102-1687

PLEASE SEE INSTRUCTIONS BELOW BEFORE ANSWERING ANY QUESTIONS ON THIS FORM

1.

APPLICANT NAME

1A. TRADE NAME (IF APPLICABLE)

2.

BUSINESS ADDRESS (NUMBER AND STREET)

CITY

STATE

ZIP CODE

3.

MAILING ADDRESS: IF DIFFERENT FROM ABOVE (NUMBER AND STREET)

CITY

STATE

ZIP CODE

4.

BRANCH OFFICE ADDRESS (IF ANY)

CITY

STATE

ZIP CODE

5.

DAYTIME TELEPHONE NUMBER

6. EVENING TELEPHONE NUMBER

FAX NUMBER

7.

FEDERAL EMPLOYER IDENTIFICATION NUMBER/SOCIAL SECURITY NUMBER

8. PA STATE SALES TAX NUMBER

E-MAIL ADDRESS

9.

INDIVIDUALS, PARTNERS OR OFFICERS NAME

10. HOME ADDRESS

11. SOCIAL SECURITY NUMBER

12. TEMPORARY PHILADELPHIA BUSINESS TAX NUMBER

13. TYPE OF ORGANIZATION (CHECK ONE)

A. SOLE PROPRIETOR

B. CORPORATION

C. ESTATE OR TRUST

14. LICENSE TYPE

FEE

REVENUE CODE

LICENSE NUMBER

Annual Business

Expires Yearly

Privilege License

$50.00

3710

each December

I understand that if I knowingly made any false statement herein I am subject to such pernalities as may be prescribed by law.

____________________________

____________________________________________________________________________________ ________________________________________________

(DATE)

(SIGNATURE)

(TITLE)

Department of Licenses and Inspections Information: (215) 686-2463

INSTRUCTIONS – PLEASE READ CAREFULLY

1.NAME OF TAXPAYER(S) OR TAX ENTITY – If a corporation, use exact legal corporate name. If a partnership, use name of partners. If an individual proprietorship, use name of owner (last name first, first name and middle initial). The entity name is the name which your account will be filed in the name printed on all tax returns mailed to you.

1A. TRADE NAME – If you operate your business under a different name than block 1, enter here.

2.BUSINESS ADDRESS – enter primary business location.

3.MAILING ADDRESS - if different than business address, enter here.

4.BRANCH OFFICE ADDRESSES – Enter only Philadelphia branch offices. 5, 6 - Self-explanatory - Contact Information -

7.FEDERAL EMPLOYER IDENTIFICATION NUMBER – This number is assigned by the Internal Revenue Service to all corporations and partnerships and to individual proprietors if they employ others. This number must be included on this form.

8.PENNSYLVANIA STATE SALES TAX NUMBER – Enter Pennsylvania Sales and Use Tax license number or Sales and Use Tax exemption number.

9, 10 & 11 - INDIVIDUAL’S PARTNER’S OR OFFICER’S NAME; ADDRESSES AND SOCIAL SECURITY NUMBER – This information is also considered a vital portion of your tax record and must be included on this form in full detail for all partners, corporate officers and/or individual owners.

12.Temporary Philadelphia Business Tax Number.

13.Check the appropriate organization.

This License will expire at the end of each calendar year along with the

Philadelphia Tax Account Number, and is not renewable.

81-76 (Rev. 9/08)