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 |
Medina Creative Solutions
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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 |
+19287722011
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| Alternate # (Emergency Phone Number) |
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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: |
HEALTH SERVICES
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| Business Description (Please describe in detail the nature of the business) |
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| Start of business date |
2023-06-01
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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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Federal Tax ID or Social Security Number
| Please provide your Federal ID or Social Security Number |
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Transaction Privilege Tax (Sales Tax)
| Transaction Privilege Tax (TPT) Number |
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Applicant Information (Must be completed by the person filling out this application)
| Name (First and Last) |
Theresa Medina
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| Home Address (No PO Boxes) |
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| Mailing Address |
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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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Application Affidavit
