APPLICATION FOR PHELPS COUNTY MERCHANTS LICENSE

$25 fee per year

NAME OF BUSINESS______________________________________________

OWNERS NAME____________________________________________________

BUSINESS ADDRESS/CITY/STATE/ZIP_________________________________

MAILING ADDRESS/CITY/STATE/ZIP_________________________________

TELEPHONE NUMBER___________________________________________________

MISSOURI SALES TAX NUMBER___________________________________________________

E-MAIL ADDRESS__________________________________________

PLEASE FILL THIS APPLICATION OUT AND FAX TO

PHELPS COUNTY COLLECTORS OFFICE

573.458.6159