DBA:_______________________________________________________________________________
NAME:______________________________________________________PHONE:_________________
PERMANENT ADDRESS:_______________________________________________________________
DRIVERS LICENSE NO. & STATE:_______________________________________________________
DESCRIPTION OF BUSINESS/MERCHANDISE:____________________________________________
LA PAZ COUNTY HEALTH PERMIT #:_______________ AZ RESALE TAX #:_____________________
BUSINESS LOCATION & SPACE #:_______________________________________________________
VALIDATED BY:______________________________PAYMENT-____CASH ____CHECK #________
DATE:__________________ APPLICANT SIGNATURE *:_____________________________________
REFUSAL TO COMPLY SHALL RESULT IN EITHER A CRIMINAL OR CIVIL CITATION FOR VIOLATION OF THIS CHAPTER. IF FOUND RESPONSIBLE, A PENALTY SHALL BE A FINE OF $250.00 FOR THE FIRST OFFENSE. IF FOUND RESPONSIBLE FOR A SECOND OFFENSE A FINE OF AT LEAST $250.00 & INELIGIBILITY TO OBTAIN A FUTURE VENDOR SALES PERMIT FOR FIVE (5) YEARS. EACH DAY A VIOLATION CONTINUES SHALL BE A SEPARATE OFFENSE PUNISHABLE AS HEREIN ABOVE DESCRIBED.
*I CERTIFY THE FACTS TO BE TRUE AND CORRECT IN ACCORDANCE WITH A.R.S. ยง13-2704(A)
_____________________________________________________________________________________________________
THIS AREA IS FOR TOWN USE ONLY.
APPLICATION SENT OUT BY ____________________________________________________ DATE___________________________
APPLICATION RECORDED IN BY ________________________________________________ DATE _______________________________
RETURN APPLICATION TO:
TOWN OF QUARTZSITE
PO BOX 2812
QUARTZSITE, AZ 85346-2812
ATTN: Reception