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Page 1

Fill in all blanks, if the question does not pertain to your business, please write N/A (not applicable). Applications will not be processed with incomplete information.

Business Information

Complete name under which the business will be conducted:

Business Phone:

Fax Number:

After Hours Emergency Contact:

First Name :	Last Name:
Phone:

Physical business location

Address:	City:
State:	Zip Code:

Is Mailing Address Different form Physical Location?

YesNo

Business Mailing Address

Address:	City:
State:	Zip Code:

Was the business previously licensed by the Town of De Beque?

YesNo

Under what name:

First Name :	Last Name :
Address:	City:
State:	Zip Code:

Nature of business (types of sales or services):

Taxpayer Information

Is legal name of taxpayer different from business owner?

YesNo

First Name :	Last Name :
Phone:

Address:	City:
Zip Code:	State:

Attach a Complete detailed explanation:

Manager Information

First Name :	Last Name :
Phone:

Type of taxpayer entity:

Individual	Limited Partnership
Corporation	Non-Profit Corporation
Unincorporated Organization	Partnership
Other

Partnership or Corporation:

Full legal name of partnership or corporation:

Federal tax identification number:

Individually Business

For individually owned businesses indicate the name and address of any owner not already included:

Owner 1

First Name :	Last Name:
Phone:

Address::	City:
State:	Zip Code:

Owner 2

First Name :	Last Name:
Phone:

Address::	City:
State:	Zip Code:

Partnerships or Limited Partnerships

For partnerships or limited partnerships, lists the name and address of each general partner:

Owner 1

First Name :

Last Name:

Phone:

Address::	City:
State:	Zip Code:

Owner 2

First Name :

Last Name:

Phone:

Address::	City:
State:

Corporations and Non-profit Corporations

For corporations and non-profit corporations, list the name and address of each officer of the corporation and for corporations other than publicly held corporations indicate the name and address of each shareholder with more than a 20% interest in the corporation other than the officers already listed:

Officer 1

First Name :	Last Name:
Phone:

Address:	City:
State:	Zip Code:

Officer 2

First Name :	Last Name:
Phone:

Address:	City:
State:	Zip Code:

Please Explain:

Is taxpayer doing business under other business names?

YesNo

All Business Names

Please indicate the name and address of each business:

Business Name 1

Business Name:

Address:	City:
State:	Zip Code:

Business Name 2

Business Name:

Address:	City:
State:	Zip Code:

Page 2

Acquired Business

Date taxpayer acquired the business:

Entity/person from which business was acquired:

Do you need the Town to provide remittance forms?

YesNo

Authorization

This application must be signed by owner, officer or partners of taxpayer as appropriate.

Signature:

Title:

Fee Amounts $3000 New Marijuana Tax License
$500 Renewal Marijuana Tax License

Need assistance with this form?

TOWN HALL

PH: (970) 283-5475

FAX: (970) 283-5205

www.debeque.org

ADDRESS

P.O. BOX 60

381 MINTER AVE.

DE BEQUE, CO 81630

WELCOME

TOWN HALL

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