Business License Application
Business License Status
| What would you like to do today: |
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| Is this a: |
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| If you are are applying for or renewing a PV liquor License, please select which Series you are applying for |
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Location/Ownership Change
| Date of the location/ ownership change: |
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Business Name and Physical Location
| Business name or Trade Name |
Vivant Behavioral Healthcare
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| Nature of Ownership |
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| Business Street Address (Physical location of the business (cannot be a PO Box) |
2517 N. Great Western Dr, Suite P, Prescott Valley, AZ 86314
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| is the business location: |
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| Mailing Address (Street name and number only) |
2517 N. Great Western Drive, Suite P
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| Mailing Address City, State, & Zip Code |
Prescott Valley, AZ 86314
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| Business Phone Number |
+19287724131
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| Number of Employees |
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| Please choose the most applicable to your business: |
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| Please read carefully through the following list and choose the closest description of your business: |
SERVICE BUSINESS
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| Business Description (Please describe in detail the nature of the business) |
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| Will your business be selling or serving alcohol? |
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| Start of business date |
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| Locations where the business or applicant has operated during the last 5 years: |
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Applicant Information (Must be completed by the person filling out this application)
| Name (First and Last) |
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| Home Address (No PO Boxes) |
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| Phone number |
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| Driver's License Number |
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| Driver's License Expiration Date |
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| Date of Birth |
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| Social Security Number (Last four (4) digits ONLY) |
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Federal Tax ID or Social Security Number
| Please enter your Federal Tax ID Number |
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Professional Licenses
| Professional License or Permit Number & Description |
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Application Affidavit
