Business Name:_______________________________________ Phone ( )________________

Is this a home-based business? _______

If yes, do you agree with the conditions listed under "Regulations for Home-Based Businesses"?____

Type of Organization: _____ Sole Proprietorship _____ Partnership _____ Corporation

Business Physical Location:____________________________________________________________

Mailing Address (if different):___________________________________________________

_________________________________________________________________________

Federal Tax Identification Number (if applicable): _______________________

Seller’s Permit Identification Number (if applicable): ______________________

Type of Business: __________________________________________________________

Business Classification Code Number (see code list): ________________

State License Number (if applicable): _________________

Date Business Opened in San Anselmo: Month________ Day ________ Yr________

Owner Information (list each owner):

   Name             Residential Address                 Phone                 Social Security #

1.________________________________________________________________________________

2.________________________________________________________________________________

3.________________________________________________________________________________

ESTIMATED GROSS RECEIPTS/EARNINGS for this calendar year: $ _______________

BUSINESS LICENSE TAX DUE (See Gross Receipts Tax Schedule ): $_______________

Signature: ______________________________ Date: ________________

 Business Licenses are issued in accordance with Title 6, Chapter 1 of the San Anselmo Municipal Code. Sales or Use Tax may apply to your business activities. You may seek written advice regarding the application of tax to your particular business by contacting the nearest State Board of Equalization office.