City of Loma Linda - Business License Application

Company name and Service of process address : (List address where each individual consents to receive service of process per AB2184 Sec.16000 1(a) (2) and 16100 1(a) (2)) *

Company Name

Address

CityState / Province

Postal / Zip Code
Business Phone Number*

Area CodePhone Number
Business Fax Number

Area CodePhone Number
Email:*
example@example.com
Product(s) sold /Description of business/Services rendered: *
Exempt

YesNo
Ownership (Please check below)*

CorporationLtd Liability CorpGeneral PartnershipLtd Liability PartnershipSole Proprietorship
Sole proprietorship, Partners or Corporate Officers: (If different from the Service of Process Address/Business Address)
Please submit the application, then call for business tax due.

Business Tax Due BLTAXN: _________
*State Mandated Fee BLSTF: $4.00
Registration Application Fee BLNEW: $85.00

Total : _________
BY MY ELECTRONIC SIGNATURE BELOW I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Electronic Signature:*

Name Title
Date*

MonthDayYear
Under federal and state law, compliance with disability access laws is a serious and significant responsibility that applies to all California building owners and tenants with buildings open to the public. You may obtain information about your legal obligations and how to comply with disability access laws at the following agencies:
- The Division of the State Architect at www.dgs.ca.gov/dsa
- The Department of Rehabilitation at www.dor.ca.gov
- The California Commission on Disability Access at www.ccda.ca.gov
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