2. Name of Corporation or LLC*
3. Doing Business As*
5. Email Address*
6. Local Business Phone Number*
7. Local Business Fax Number
9. Local Business Street Address*
11. City*
12. State*
13. Zip Code*
15. Mailing Address (if different)
17. City
18. State
19. Zip Code
21. Website URL

25. List owners, partners or corporate officers

27. Name and Title
28. Home Address
30. Phone Number
31. Email Address
33. Name and Title
34. Home Address
36. Phone Number
37. Email Address
39. Name and Title
40. Home Address
42. Phone Number
43. Email Address
45. Person making application is:
    -- Select One --OwnerManagerAgent
47. Applicant Name and Title
48. Applicant Social Security Number
50. Applicant Home Address
52. Applicant Phone Number
53. Applicant Email Address
55. Applicant Date of Birth
56. Applicant Drivers License and Issuing State
60. BUSINESS DESCRIPTION:

    Give a concise description of the business to be conducted including products and/or services provided. Any misrepresentation in the description of the business by the applicant may be sufficient cause for the application to be rejected. 

62. Description

66. RETAIL SALES ONLY:

68. Do you sell any products?
    -- Select One --YesNo
69. Do you charge sales tax?
    -- Select One --YesNo
71. The amount of all merchandise at cost, held by the above named business, for sale is declared to be?

    I understand that my City of Nevada merchant's license for next year will be based on this true and accurate figure. 

75. DOOR-TO-DOOR ONLY:

77. Will you go door-to-door?
    -- Select One --YesNo
78. Number of persons going door-to-door
80. List dates you plan to go door-to-door

82. If the work or goods you sell will not be done by your immediate employer, state the name and address of the entity that will provide the goods or services:

84. Business Name
85. Business Phone Number
86. Business Fax
88. Business Street Address
90. City
91. State
92. Zip Code

96. I hereby certify that the business or occupation I intend to pursue under the authority of the license for which I am applying does not violate or otherwise conflict with existing laws of the State of Missouri or ordinances of the City of Nevada. I also acknowledge that this is only an application and is not approval for me to conduct business within the City of Nevada, Missouri.

98. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

99. Electronic Signature*

    1. I agree
101. Applicant Signature*
102. Date*
     Date
104. REQUIRED ATTACHMENTS

     1. All businesses located inside city limits:

     Vernon County Business Paid Personal Property Tax Statement OR

     Vernon County Assessor Certificate of No Tax Due (new businesses established after January 1)

      2. Retailers:

     Missouri Retail Sales License (new applications only) Missouri Certificate of No Sales Tax Due

     3. Food Establishments:

     Health Inspection (new applications only)

     4. Contractors:

     Certificate of Workers Compensation Insurance if one or more employees Affidavit of Exemption from Workers Compensation if no employees Certificate of Liability Insurance

     Plumbing and Electrical only- submit a list of all master, journeymen and apprentices

      5. Door-to-Door:

     List all persons going door-to-door: home address, home phone number and criminal history for the past 7 years. 

     Criminal history: month, year and court jurisdiction for each infraction of traffic, misdemeanor and felony convictions 

     Submit a copy of all persons valid driver's license

     Background check reports for all persons: Missouri State Highway Patrol website- www.mshp.dps.missouri.gov 

     Fingerprints for all persons- Nevada Police Department 417-448-5100

     Listing of all vehicles: year, make, model, color license plate and state. and license plates

106. File Upload
107. File Upload
108. File Upload
109. File Upload
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field