Business License Application
Business License Status
| What would you like to do today: |
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Business Name and Physical Location
| Business name or Trade Name |
Blue Line Medical
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| Amount of properties owned in Prescott Valley: (per parcel #) |
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| Location of Commercial Building Rental(s): |
8841 E Florentine Rd. Suite B. Prescott Valley, AZ. 86314
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| Building owner's physical location: |
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| Nature of Ownership |
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| Mailing Address (Street name and number only) |
8841 E. Florentine Rd.
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| Mailing Address City, State, & Zip Code |
Suite B
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| Business Phone Number |
+19284701005
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| Alternate # (Emergency Phone Number) |
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| Start of business date |
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| Description of your business: |
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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 are accepted) |
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| Phone Number |
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| *Check the boxes 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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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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| Email Address |
[email protected]
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Federal Tax ID or Social Security Number
| Please enter your Federal Tax ID Number |
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Application Affidavit
