2. Date
   Date
4. Name of Business
5. Business Phone
7. Street Address
9. Mailing Address
11. City
12. State
13. Zip Code
15. Classification of Business
    Briefly describe the major line/primary type of business/service to be offered.
17. Number of full-time employees:
    Includes owner/manager
18. Number of part-time employees:
19. Anticipated number of hours to be worked by part-time employees:
21. Plumbing/HVAC/Electrical Contractors must furnish State Certification Number:
23. Owner's Name
24. Owner's Phone Number
26. Email Address
28. Owner's Address
30. City
31. State
32. Zip Code
34. Note:
    All licenses must be renewed by March 31 of each year regardless of the date of issuance. Licenses are not transferable from one person to another or business. Certain applications/stipulations may apply and may require the approval of the Mayor and Council. Please call Grovetown Licensing & Permits with any questions at 706-860-5094.
36. I certify that the above information is true and correct. I understand that falsification of any part of this application could cause denial, suspension, or revocation.
38. Signature of Applicant/Owner
39. Date
    Date
41. Approved/Denied

    1. Approved
    2. Denied
42. Date Approved
    Date Approved
44. License Number
45. Council Approval
46. Meeting Date
    Meeting Date
48. Mayor
49. City Clerk
53. Zoning Recommendations
57. By signing/affixing signature below, I, the applicant/owner of the above noted business do hereby state that I have read and fully understand the noted stipulations for obtaining an occupational license for the above named business. I further state that I am aware that failure to comply with the stipulations will result in the suspension or revocation of said occupational license.
59. Signature of owner/applicant
60. Date
    Date
64. O.C.G.A. §50-36-1(e)(2) Affidavit
    O.C.G.A. §50-36-1(e)(2) Affidavit (PDF)

    This Affidavit must be completed.
65. Upload Completed Affidavit*
67. Private Employer Exemption Affidavit Pursuant to O.C.G.A. §36-60-6(d)
    Private Employer Exemption Affidavit (PDF)

    Complete if you have 10 or less employees.
68. Upload Completed Affidavit*
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70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field