Business License Application
Business Status
| What would you like to do today: |
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New Application
| Is this a: |
None of the above
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Business Name and Physical Location
| Business Name or Trade Name |
Empowered Life Hypnotherapy
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| Business Street Address (Physical location of the business cannot be a PO Box) |
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| Mailing Address (Street name and number only) |
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| Mailing Address City, State, & Zip Code |
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| Business Phone Number |
+18057577687
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| Number of Employees |
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| Please read trough the list carefully and select the closest description of your business: |
MENTAL/BEHAVIORAL SERVICES
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| Business Description (Please describe in detail the nature of the business) |
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| Start of business date |
2023-03-16
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| Locations where the business or applicant has operated during the last five (5) years |
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| is the business location: |
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| Nature of Ownership |
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Individual/ Sole Proprietor Owner Information (Eligibility Form)
| Name (First and Last) |
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| Title |
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| Home street address (cannot be a PO Box) |
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| Social Security Number (Last four (4) digits only) |
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| Phone Number |
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| *Check the box next to the document you are presenting to the Town, indicating lawful presence |
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| Attach a copy of said document |
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Professional Licenses
| Upload File |
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| Professional License or Permit Number & Description |
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Applicant Information (Must be completed by the person filling out this application)
| Name (First and Last) |
Brianna Kukawsky
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