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2. Account Number
3. License Number
5. Business Name
6. Trade Name
8. Location Address
10. Business Owner Name*
11. Contact Phone Number*
13. Email Address*
15. Effective Date
    Effective Date

    Effective Date

19. ATTENTION RESTAURANT OWNERS: 

    Please continue and complete the information below:

21. Question

    1. Yes
    2. No

22. I grant permission to the City of Norfolk to use my cash bond to pay any outstanding invoices due and to refund the difference to:

24. Make Payable to:
25. Mailing Address:
27. Question

    1. Yes
    2. No

28. I grant permission to the City of Norfolk to transfer my cash bond to the New Owner:

30. New Owner Name:
32. New Business Name:
34. New Business Location:
36. Owners Signature:
37. Date/Time:
    Date/Time:

    Date/Time:

39. SIGNATURE. I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM AND ON THE ATTACHED AFFIDAVIT IS TRUE, CORRECT AND COMPLETE. I FURTHER DECLARE THAT I AM AUTHORIZED TO FILE THIS FORM AND I UNDERSTAND THAT THE PENALTY FOR FILING FALSE INFORMATION IS PUNISHABLE BY LAW. I FURTHER UNDERSTAND THAT THIS INFORMATION SHEET AND ATTACHED AFFIDAVIT DOES NOT GRANT ME PERMISSION TO PERFORM ANY ACTIVITY THAT IS DEEMED ILLEGAL IN THE STATE OF VIRGINIA.

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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field