2. Instructions

   This form must be filled out completely and submitted using the submit or submit and print button on the bottom of the form.   

4. Fee

   Town of Kersey Business License: $25.00

   Payment must be received within 15 days of submission. Please call 970 353 1681 ext.1 to pay for the license by credit card. You may also send a check to the Town of Kersey PO Box 657, Kersey, CO 80644.  Licenses without payment will not be processed.

6. License to be issued to:*
8. Type of Ownership:*

   1. Association
   2. Corporation
   3. Individual

   1. Partnership
   2. Other
10. Trade name (if any):*
12. Business Location*
14. City*
15. State*
16. Zip Code*
18. Mailing Address*
20. City*
21. State*
22. Zip Code*
24. Phone*
25. Email Address*
27. Sales Tax Number*
29. Product(s) or service(s):*
31. Names of partners or officers of business:*
33. "I declare, under penalty of perjury, that this application has been examined by me and the statements made herein are made in good faith pursuant to the Town of Kersey tax laws and regulations and to the best of my knowledge and belief, are true, correct, and complete"
35. Applicant's or Agent's Signature*
36. Date*
    Date
38. Title*
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field