2. Assumption Parish Police Jury Application for Occupational License
4. ***Licenses become due and payable January 1st, and become delinquent April 15th
6. Date*
   Date
   Enter the date
7. Phone Number*
   Enter your phone number
9. Trade Name:*
   Enter your trade name
10. Owner Name:*
    Enter the Business owner's name
12. Business/Contact Email Address:*
    Enter the business/contact email address
14. Physical Location of Business:*
    Enter the physical address of the business
16. Mailing Address
    Enter your address if it is different from the physical address
18. BUSINESS DATA:
20. Type of business, profession, vocation, etc.:*
    Enter the type of business, profession, vocation, etc.
22. Does your business dispense food and/or beverages?*

    1. Yes
    2. No
24. Does your business dispense alcoholic beverage?*

    1. Yes
    2. No
26. Does your business have a video poker machine?*

    1. Yes
    2. No
28. Does your business have amusement devices?*

    A list of machines and locations must accompany this application.

    1. Yes
    2. No
30. If applicable, upload a list of machines and locations:
32. Exceptions to occupational license: Peddlers, Fireworks
34. ***If any of the above qualifications are not possessed by the applicant, the permit may be denied at the discretion of the police jury.
36. THE ISSUANCE OF THIS LICENSE DOES NOT EXEMPT THE TAXPAYER FROM OBTAINING ANY NECESSARY STATE OR PARISH PERMITS/LICENSES.
38. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature*
42. ***AFTER APPROVAL FROM THE POLICE JURY, APPROVED APPLICATION EMAIL SHOULD BE TAKEN TO THE ASSUMPTION PARISH SHERIFF'S OFFICE FOR ISSUANCE OF ACTUAL OCCUPATIONAL LICENSE WITHIN 10 DAYS.
44. Secretary-Treasurer Approval

    By checking the "I approve" box below, you agree and acknowledge that 1) your approval will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, 3) you may still be required to provide a traditional signature at a later date, and 4) you are approving this occupational license.

    1. I approve.
46. Electronic Signature
47. Date of Approval
    Date of Approval
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field