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2. County of Dinwiddie
   Office of the Commissioner of the Revenue
   

   P.O. Box 104, Dinwiddie, VA 23841
   Ph: 804-469-4500 x4 Fx: 804-469-4548

4. You may send a copy of your Tradesman's License or Certification by fax at 804-469-4548, or email Beth Mingloski.
   
   Or you may provide the following information on this form.
6. Dinwiddie County Business License Account Number
8. Tradesman's Name
10. Tradesman's State of Virginia Tradesman's License/Certification Number*
12. Trades
13. Expiration Date
15. You can obtain your Tradesman's License/Certification Number as follows:
    Go to the DPOR website
    Select "License Lookup" in the left navigational menu
    Enter your name in the "Name" box
    Select the appropriate occupation from the list (e.g., "Contractor - Individual Licenses/Certifications")
    Click on the "Search Licenses" button

17. Certification

    It is a misdemeanor for any person to willfully subscribe a return which is not believed to be true and correct as to every material matter. (Code Va. Sec. 58.1-11)
    
    DECLARATION: I declare, under penalty of perjury, that the foregoing information is complete, true and correct to the best of my knowledge and belief.
19. Signature
20. Print Name
21. Title
22. Date
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23. Print Only

* indicates a required field