City of Radford Virginia
Commissioner of the Revenue
Cathy Flinchum, MCR
619 Second Street, Room 161
Radford, VA 24141

Business/Trade Name:

Federal ID#

Physical Address

Mailing Address:

Business Phone

Owner/Contact Name

Owner/Contact Phone

Owner/Contact Email

Home Address of Contact Person

Class (Restaurant, Cafeteria, Delicatessen, Snack Bar, Food Truck, etc.)

Type of Ownership (Individual/Partnership/Corporation)

Name of Official Signing (if Corporation)

Open Date of Business

Name of Business Succeeding

Name of Bank

Account Number

Signature

Title

Date

*Separate Registration Form Required for Each Location*