Business Information

Business Name*

Business License #*

Business Address*

Type: *

Restaurant Retail

bar/nightclub/lounge

Number of Locations Worldwide:*

Franchise?*

Yes

No

Gross Sales (Prev Year): *

< $50,000 $50,000 - $99,999 $100,000 - $149,999 $150,000 - $199,999 > $200,000

Number of Employees in Emeryville Location*

Number of Employees (Companywide)*

Applicant Information

Applicant Name*

Relationship to Business*

Mailing Address (if different from Business Address)

Street*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip*

Phone Number*

Email*

Requesting Rebate of:*

Business License Tax Fire Inspection Fees

Cabaret License Fees Sidewalk Signs Permit Fee

Date Fees Paid

Program Questions

My business is: *

Growing Stable Declining

For my business, the Business License Rebate Program is: *

Unnecessary Somewhat Helpful Very Helpful Critical

Please suggest any other incentives or assistance programs that the City could offer to help your business thrive:

Please upload your W9 form.*

Submittal / Certification

By submitting this form I certify the aforementioned business applying for a rebate is not subject to any active investigations for violations of the City of Emeryville codes including, but not limited to Planning, Building and Fire codes, the Minimum Wage and Paid Sick Leave Ordinance, or any other City code, ordinance or regulation. By submitting this form, I also certify that I am authorized to submit this application for rebate of Business License Tax and / or Fire Inspection Fees on behalf of the aforementioned business.

ACCEPT TERMS*

I accept