Business License Update Form

BUSINESS LICENSE UPDATE FORM

Licensing Authority:    Business Name:    Existing License No.:

RECITALS

WHEREAS, the Licensing Authority identified above administers and issues business licenses and is authorized to record updates or amendments to issued licenses under applicable local regulations and ordinances; and

WHEREAS, Business Name: currently holds license number and seeks to submit updates to the official license record; and

WHEREAS, the parties desire to document and effect the requested updates subject to the terms, fees, and certifications contained in this form.

UPDATE REQUEST

Select the type(s) of update requested (check all that apply):

Change of Address Change of Ownership / Registered Agent Change of Trade Name / DBA Change to Business Activities / NAICS Change of Officers / Principals Add / Remove Location Other:

NEW INFORMATION

SCOPE OF UPDATE

Provide a concise description of the changes to be recorded on the license certificate and any operational impacts. Attach supporting documentation where required.

EFFECTIVE DATE

Requested Effective Date:

PAYMENT TERMS

Fee Amount:    Payment Due Date:

Payment Method: Check Credit Card Electronic Cash

Late Fee: A late fee of USD or percent of the outstanding amount, whichever is greater, shall apply to payments received after the Payment Due Date.

TERM AND TERMINATION

Term Start Date:    Term End Date (if applicable):

Either party may request administrative rescission of the recorded update by providing written notice to the other party. Notice Period: days prior to the requested rescission date. The Licensing Authority may suspend or revoke licensure in accordance with applicable rules for material misstatements or noncompliance.

CONFIDENTIALITY

Information submitted on this form will be maintained in the Licensing Authority's records. Except as required by law, the Licensing Authority will treat information marked confidential in accordance with applicable confidentiality rules. The applicant acknowledges that some information (including business name, trade name, and license status) may be public record.

GOVERNING LAW

This form and any recorded updates shall be governed by the laws of the jurisdiction in which the Licensing Authority operates. Governing State / Jurisdiction:

ENTIRE AGREEMENT

This form, together with any attachments and supporting documentation submitted contemporaneously, constitutes the entire record of the requested license update between the applicant and the Licensing Authority with respect to the matters addressed herein. No other statements, representations, or agreements, oral or written, shall modify or supersede this submission unless executed in writing by the authorized representative of the applicant and acknowledged by the Licensing Authority.

CERTIFICATION

I certify under penalty of perjury under the laws of the governing jurisdiction that the information provided on this form and any attached documentation is true, complete, and accurate to the best of my knowledge. I understand that material misrepresentation or omission may subject the license to suspension, revocation, or other administrative or criminal penalties.

Sole Proprietor Corporation LLC Partnership Other:

Attachments Included (check all that apply):

Certificate of Formation / Incorporation Government ID for Authorized Rep Power of Attorney / Authorization Other:

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