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Get Va Vwc 61-a 2012

applies for or renews a business license Locality Issuing License: City Town Name of Locality: PLEASE COMPLETE FULLY AND LEGIBLY Business or Trade Name Business License Number: County Name of Applicant Business FEIN or Tax ID Number: Last: First: Applicant Mailing Address: City: Business Address: State: Zip: Home Telephone: City: State: Business: Corp. M ETHOD of W ORKERS’ COM PEN SATION IN SURAN CE: Indicate One: Insurance Carrier licensed in Virginia Self insured with ce.

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