City of Byron - New Business Application

Affidavit Verifying Status

(O.C.G.A. § 50-36-1(e)(2) Affidavit)
Please read carefully before completing
- Affidavit must be notarized.
- Include a copy of applicant’s secure and verifiable identification document. A list of secure and verifiable documents is provided by the Attorney General on the Georgia Department of Law website.
By executing this affidavit under oath, as an applicant for a(n) Business License/Occupation Tax Certificate, as referenced in O.C.G.A. § 50-36-1, from the City of Byron, Georgia, the undersigned applicant verifies one of the following with respect to my application for a public benefit:*

I am a United States citizen. (Provide state issued identification document (i.e. - driver’s license)I am a legal permanent resident of the United States. (Provide copy of alien registration document)I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency.(Provide copy of alien registration document)
My alien number issued by the Department of Homeland Security or other federal immigration agency is:
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The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(I), with this affidavit.

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties allowed by such statute.
Executed incity , state
SUBSCRIBED AND SWORN BEFORE ME ON THIS THEday DAY OFmonth , year
Printed Name of Applicant*

First NameLast Name
Signature of Applicant*

Clear
NOTARY PUBLIC
My Commission Expires

Private Employer Affidavit

Pursuant To O.C.G.A. § 36-60-6(d)
By executing this affidavit under oath, the undersigned private employer verifies one of the following with respect to its application for a business license, occupational tax certificate, or other document required to operate a business as referenced in O.C.G.A. § 36-60-6(d):
Section 1. Please check only one:*

(A) On January 1st of the below-signed year, the individual, firm, or corporation employed more than ten (10) employees*.(B) On January 1st of the below-signed year, the individual, firm, or corporation employed ten (10) or fewer employees.
* To determine the number of employees for purposes of this affidavit, a business must count its total number of employees company-wide, regardless of the city, state, or country in which they are based, working at least 35 hours a week.
Section 2.
The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and deadlines established in O.C.G.A. § 36-60-6. The undersigned private employer also attests that its federal work authorization user identification number and date of authorization are as follows:
Name of Private Employer*
Federal Work Authorization User Identification Number*
Date of Authorization*

MonthDayYear
- I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on Date* in city* , state* .
Signature*

Clear
Signature of Authorized Officer or Agent
Printed Name and Title of Authorized Officer or Agent
My Commission Expires
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THEday DAY OF month .
year

New Business 911 Emergency Contact
Business Name*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Owner*

First NameLast Name
Emergency Contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Alternate Keyholder Contact:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Does Business have an alarm?*

YesNo
Are there security cameras? If yes, Inside/Outside ?
Security Company (if monitored by them)
Any additional information 911 personnel should know in an emergency?
Signature*

Clear
Please verify that you are human*
Should be Empty:

APPLICATION FOR OCCUPATIONAL TAX LICENSE

SECTION 1: BUSINESS INFORMATION

Affidavit Verifying Status

Private Employer Affidavit

New Business 911 Emergency Contact