Renew RME License

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):

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

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