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2. Margaret S. Torrence
   Commissioner of Revenue
   Franklin County, Virginia
   1255 Franklin St., Suite 102
   Rocky Mount, VA 24151
   Phone: (540) 483-3083
   Fax: (540) 483-3089
4. Reason for submitting form:*

   1. Address Change
   2. Name Change
   3. New Account
5. Entity Type

   1. Corporation
   2. LLC
   3. Partnership
   4. Sole Proprietorship
7. Former Business Name or Trade Name*
9. Business Name*
11. Trading as Name
12. Contact Person Name:
14. Business Location Address*
    Enter your street address
16. City*
17. State*
18. Zip Code*
20. Is mailing address the same as above?*

    1. Yes
    2. No
22. Mailing Address*
    Number and Street Name or PO Box
24. City*
25. State*
26. Zip Code*
28. Business Phone*
29. Cell Phone
31. Home Phone
32. Fax Number
34. Email Address
35. Website Address
37. Start Date in Franklin County*
    Start Date in Franklin County
38. Start Date at This Location
    Start Date at This Location
40. Estimated Gross Receipts by December 31
42. Description of Business Activity (Work performed, services provided, products sold, peddler, amusement machines, itinerant merchant):*
44. If a Corporation, List Virginia Registration Agent Name and Address:*
46. List Name of Members or Corporate Officers:*
50. CONTACT PLANNING & COMMUNITY DEVELOPMENT
    Please contact the Franklin County Planning & Community Development Office at 540-483-3027 to inquire on zoning regulations that may apply to your business.
52. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
54. Electronic Signature
55. Title
56. Date
    Date
58. IMPORTANT MESSAGE: The Commission of Revenue office will contact you via phone or email to obtain additional information needed to process this request.
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field