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<br />Address <br /> <br />Annual License Fee $200.00 <br />Mobile License Fee $100.00 <br /> <br />Fees are payable prior to January 1st of each year and are effective throu!:lh December 31st. <br />$25.00 Late Fee <br /> <br />Date <br /> <br />Signature <br /> <br />Title <br /> <br />(Please do not write below this line) <br /> <br />The foregoing application is hereby approved and it is recommended that a license be issued, <br />subject to the following provisions: <br /> <br />Approved by <br /> <br />Date <br /> <br />Health Officer or Representative <br /> <br />Receipt Date <br /> <br />Check No. <br />