Business Name  

Your e-mail address  

Business Physical Location  

Business Mailing Address  

City  

State  

Zip Code  

Business Phone Number  

Brief describe the major line or primary line of business or service to be offered

Enter the average number of full-time employees, working within the City of Bainbridge, for the year. Count the part-time employees as a fraction of full-time employees on a man-year basis. (I.E.--A firm with 6 full-time employees and 5 part-time employees would report 8.5 employees). Number of employees  

Expect gross receipts for all business conducted in Bainbridge  

Owner of business  

Manager of the business  

Plumbing, Heating A/C, and Electrically Contractors State Certification Number  

State Certification Expiration Date  

Gas Plumbers list name of insurance company  

If you are an out-of-town contractor, does your business possess a valid Occupational Tax Certificate elsewhere in the State of Geogia?
Yes   No  

If your business holds a Certificate elsewhere, what is the expiration date of that Certificate?  

What were the Gross Reciepts reported to that jurisdiction?  

I hereby certify that I am authorized to commit that above listed business and the above listed information is correct to the best of my knowledge. I understand any falsification of this application could result in its denial or revocation.

Signature:(type in all capital letters to electronically sign)  

Date