TOWN OF INDIALANTIC

216 Fifth Ave. Fl. 32903 (321)-723-2242

Fax (321) 984-3867

Brevard County, Florida 32903

APPLICATION FOR OCCUPATIONAL LICENSE

VENDING MACHINES

BUSINESS NAME_________________________________________________________

BUSINESS ADDRESS______________________________________________________

BUSINESS PHONE_____________________

LOCATION OF MACHINES:

Business Name__________________________

Business Address________________________

Type of Machine _____ Serial #

_____________________________ Serial #________________________

CODE SECTION 9-11 (22) VENDING MACHINES (each machine) $30.00

I hereby declare the above statements to be true and correct to the best of my knowledge and belief.

_____________________________________ ______________________________

Signature of Applicant Date

_____________________________________

Name of Applicant (Print)

Home Address ___________________________________

___________________________________

Home Phone __________________________