Trade Name:                
	Owner's Name:              
	Business Location Address: 
	Mailing Address:           
	Business Phone:            	Home Phone: 
	Email Address:             
	
	Description of Business (give details):
	

	Indicate Ownership   Individual Partnership Corporation

	List partners or corporate officers including title and phone number:
        Name                      Title                     Phone
	          
	          
	          
	          
	
	Business was formerly operated by:                
	Have you ever had a West Plains Business License? YES  NO
 	 If Yes, what was the company name?                
	Are you a construction type business:             YES  NO
	 If Yes, how many employees do you expect to hire? 
	 (Proof of workmen's compensation insurance is required as per S.B. 251 and Ordinance NO.3394
	   for construction companies employing one or more persons.)
	Sales Tax ID Number (copy must be attached):      
	Do you plan to sell prepared food?                YES  NO
	 If "Yes" a copy of the health inspector's certificate must be attached.
	Opening Date:                                     


Owner Signature: _________________________________  Date of Application: