Business License Application
Business License Status
| What would you like to do today: |
---
|
| Is this a: |
---
|
| If you are are applying for or renewing a PV liquor License, please select which Series you are applying for |
---
|
Location/Ownership Change
| Date of the location/ ownership change: |
---
|
Business Name and Physical Location
| Business name or Trade Name |
Genoa Healthcare LLC
|
| Nature of Ownership |
---
|
| Business Street Address (Physical location of the business in the Town of Prescott Valley (cannot be a PO Box) |
181 Whipple Street, Prescott, AZ 86301-1705 Suite P1
|
| is the business location: |
---
|
| Mailing Address (Street name and number only) |
11000 Optum Circle, Suite 100
|
| Mailing Address City, State, & Zip Code |
Eden Prairie, MN 55344
|
| Business Phone Number |
+19284993198
|
| Number of Employees |
---
|
| Please choose the most applicable to your business: |
---
|
| Please read carefully through the following list and choose the closest description of your business: |
RETAIL BUSINESS
|
| Business Description (Please describe in detail the nature of the business) |
---
|
| Will your business be selling or serving alcohol? |
---
|
| Start of business date |
---
|
| Locations where the business or applicant has operated during the last 5 years: |
---
|
Applicant Information (Must be completed by the person filling out this application)
| Name (First and Last) |
---
|
| Home Address (No PO Boxes) |
---
|
| Phone number |
---
|
| Driver's License Number |
---
|
| Driver's License Expiration Date |
---
|
| Date of Birth |
---
|
| Social Security Number (Last four (4) digits ONLY) |
---
|
LLC Ownership Information
| State in which the LLC was legally established |
---
|
| 1. Name of Owner (First and Last) |
---
|
| Title |
---
|
| Home Street Address of Owner (Cannot be a PO Box) |
---
|
| Telephone Number |
---
|
| For Additional Names (Presidents, CEO, Managers), Please attach a list |
---
|
Federal Tax ID or Social Security Number
| Please enter your Federal Tax ID Number |
---
|
Professional Licenses
Application Affidavit
