CITY OF HARLEM

P.O. BOX 99
HARLEM, GA 30814

APPLICATION FOR OCCUPATION TAX CERTIFICATE

FOR YEAR: ____________             DATE: ________________________________________

NAME OF BUSINESS: _______________________________________________________________

BUSINESS TYPE: __________________________________________________________________

BUSINESS LOCATION: ______________________________________________________________

MAILING ADDRESS: ________________________________________________________________

                 ________________________________________________________________

NAME OF PARTNERS OR OFFICERS OF FIRM: ___________________________________________

NUMBER OF EMPLOYEES: ____________________________________________________________
(Including owners, partners, temporary, etc.)

I (We) do hearby certify that the following information for my business or profession as reported herein is true and correct.

                                     (Signed)____________________________________
 

---------- For Office Use Only ----------

   License No: _____________________

  License Fee: _____________________

      Penalty: _____________________

        Total: _____________________

Date Received: _____________________

  Date Issued: _____________________

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