TOWNSHIP OF IRVINGTON
Department of Revenue & Finance
Division of License
Municipal Building - Civic Square
Irvington, New Jersey 07111
973-399-6620

MISCELLANEOUS - BUSINESS LICENSE APPLICATION

BLOCK # ___________ LOT # ___________



DATE __________________ AMOUNT PAID ______________

CERTIFICATE OF OCCUPANCY NUMBER: M# ________________________________
*APPLY IN ROOM #210 OR CALL 973-399-6611

THIS APPLICATION MUST BE CORRECTLY FILLED OUT AND SWORN TO, FALSE STATEMENTS WILL BE CAUSE FOR REJECTION OR REVOCATION OF THE LICENSE.

DEAR DIRECTOR: THE UNDERSIGNED HEREWITH APPLIES FOR A LICENSE TO OPERATE AND OR CARRY ON THE FOLLOWING BUSINESS:

TOTAL AMOUNT IF LICENSE FEE(S)_______________________________________________

TRADE NAME OF BUSINESS______________________________________________________

BUSINESS ADDRESS_____________________________________________________________

BUSINESS PHONE NUMBER_______________________________________________________

THE BUSINESS IS OWNED BY:
AN INDIVIDUAL_____ A PARTNERSHIP_____ A CORPORATION_____

FULL NAME OF APPLICANT______________________________________________________

HOME ADDRESS_______________________________________________________________

SOCIAL SECURITY NUMBER ____________________________

DATE OF BIRTH ______________________________________

CORPORATION NAME__________________________________________________________

APPLICANT'S TITLE IN THE CORPORATION_________________________________________

FEDERAL TAXPAYER I.D. NUMBER OF THE CORPORATION____________________________

HAVE YOU EVER BEEN CONVICTED OF A CRIME_____________________________________

ALL COIN OPERATED VENDING MACHINES MUST BE LICENSED.

WILL YOU HAVE ANY TYPE OF COIN OPERATED VENDING MACHINE LOCATED WITHIN YOUR ESTABLISHMENT? ___________________________________

THE VENDING MACHINES ARE OWNED BY__________________________________________

NEW JERSEY STATE TAX CERTIFICATE NUMBER____________________________________

_______________________________________
SIGNATURE OF APPLICANT
_______________________________________
DRIVER'S LICENSE NUMBER

SUBSCRIBED AND SWORN TO BEFORE ME
THIS ________ DAY OF _______________, 20____

  
_________________________________________
NOTARY PUBLIC