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

   1. Corporation
   2. LLC
   3. Partnership
   4. Sole Proprietorship
6. Business Name*
7. Trading as Name
9. Contact Person Name
10. Virginia State Sales Tax #
12. Registered Agent Name*
13. Registered Agent Address*
15. Business Location Address*
    Enter your street address
17. City*
18. State*
19. Zip Code*
21. Is the mailing address same as above?*

    1. Yes
    2. No
23. Mailing Address*
    Enter your mailing address (Number and Street Name or PO Box)
25. City*
26. State*
27. Zip Code*
29. Business Phone*
30. Cell Phone
32. Home Phone
33. Fax Number
35. Email Address
36. Website Address
40. Event Name*
41. Event Date(s)*
    Event Date(s) Start Date

    —

    Event Date(s) End Date
43. Event Location*
    Name and address where event will be held
45. Estimated Gross Receipts to December 31
47. Vendor Type*

    1. Caterer
    2. Food Truck/Food Event Vendor
    3. Restaurant
    4. Other
48. List if Other:*
50. Description of Business Activity (Work Performed, Services Provided, Products Sold, Peddler, Amusement Machines, Itinerant Merchant):*
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. Date
    Date
57. IMPORTANT MESSAGE: The Commissioner of Revenue office will contact you via phone or email to obtain additional information needed to process this request.
Leave This Blank:


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

    This field is not part of the form submission.

61. Submit

* indicates a required field