Randolph County Merchant License Application

Date of Application

Please Select One:

NEW - Randolph County Merchant

RENEWAL - (No Changes)

RENEWAL - (Updated Information)

Blank Space for Filler

Business Address Section

Business Address to appear on merchant license.

Business Name

Business Telephone:

Business Address (street, city, state, Zip):

Owners Name:

Owners Phone:

Owners Mailing Address( street, city, state, Zip):

Missouri Sales Tax Number:

Nature of your business:

Type of Sales (check one):

Retail

Wholesale

Both types of sales. (RSMo150.100)

Neither One

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The State of Missouri requires that verification of Workers' Compensation Insurance be given before any municipality or county can issue a license for businesses in the following categories.

Please check if applicable:

Construction; one (1) or more employees(s)

Non-Construction; five (5) or more employees

Not Applicable

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Please Note: If you CHECKED EITHER LINE ABOVE, you are required under Chapter 287 RSMo to provide Workers' Compensation Insurance. If this applies, please attach a copy of your insurance certificate. Please sign the "Exempt" line below if this does not apply. If this application is completed online, your digital signature is the legal equivalent of a signed document.

Signature (if completing online type your full name):

Date:

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Missouri Revised Statutes §150.100 states, "No person, corporation, co-partnership, or association of persons shall deal as a merchant without a license. Each offender shall, upon conviction, be deemed guilty of a misdemeanor."

Please indicate which manner you would prefer to pay the $25.00 license fee:

Payment will be mailed with application.

Send statement for immediate payment.

Mailing or Email Address for online payment information:

Signature of Applicant (if completing online type your full name):

Printed Name (if submitting online please retype your name)

Application Date:

Merchant License application

Merchant License Application