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2. Date of Application
   Date of Application
3. Mississippi Tax ID
5. Applicants Name
6. Business Name
8. Business Address
10. City
11. State
12. Zip Code
14. Business Location
15. Telephone Number
17. Type of Business

    1. Manufacturer
    2. Non-Manufacturer
    3. Wholesale
    4. Retail
    5. Service
18. Ownership

    1. Corporation
    2. Partnership
    3. Proprietorship
    4. Professional Association
    5. Other
20. License must be renewed and payment received prior to expiration date to avoid penalty.
22. Total Number of Full Time Employees
24. Wholesale Retail
26. Amount of Assessed Inventory (nearest dollar)
27. If you sell beer (fee $30.00)
29. Game Machines (list quantity) fee $45/each
30. Vending Machines (quantity) fee $10/each
32. Kiddy Rides (quantity) fee $18/each
33. Music Machines, fee $27/each
35. Do you sell food?
37. Other Type of Business Fee
38. Manufacturer's Fee
40. Total Privilege License Fee Due
42. I hereby certify that all information given on this application for the purpose of securing a privilege license and determining the amount due,is true and correct.
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44. 1. Receive an email copy of this form.
45. Email address

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46. Submit Submit and Print

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