Business Directory Information Form

4. Town of Purcellville Business Directory Submission Form
   We are excited about publishing an online directory of all businesses located in the Town of Purcellville. Please enter your information below. You can contact us at business@purcellvilleva.gov with any questions.
8. Opt-Out

   If you do not wish to be included in the online business directory, please select the check box here.

   1. Do not include me in the Business Directory
12. Business Contact Information
    Enter the contact information for your business
14. Business Name*
    Enter the name of your business as you want it to appear.
16. First Name
17. Last Name
19. Address1*
21. Address2
23. City*
24. State*
25. Zip*
27. Business Phone*
    Enter Main Business Phone Number
28. Business Phone 2
    If desired, enter a second Business Phone number.
30. Business Email Address*
    Email address for contacting business or proprietor.
32. Business Website
    Website address for business.
36. Business Profile
    Enter a brief profile of your business.
38. Business Type 1*
    -- Select One --Retail/ShoppingRestaurant/Coffee/TeaProfessional ServicesIndependent ContractorNon-ProfitEducational EntityReligious EntityMedical ServicesRecreationAutomotive ServicesOther

    Choose your primary business type.
39. Business Type 2
    -- Select One --Retail/ShoppingRestaurant/Coffee/TeaProfessional ServicesMedical ServicesEducational EntityReligious EntityAutomotive ServicesRecreationNon-ProfitIndependent Contractor

    If you wish, choose a secondary Business Type.
41. Description of Business
    Provide a brief description of your business and services provided (max 255 characters).
43. Affirmation*

    I affirm the information contained herein is accurate.

    1. Yes
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field