Form Gro-210 - Vending Machine Addendum 2001 printable pdf download

Form Gro-210 - Vending Machine Addendum 2001

TENNESSEE DEPARTMENT OF REVENUE

500 DEADERICK STREET

ANDREW JACKSON STATE OFFICE BUILDING

NASHVILLE, TN 37242

GRO

VENDING MACHINE ADDENDUM

210

STREET OR ROUTE, P.O. BOX #

NAME (GIVE TRADE NAME AT THIS LOCATION)

CITY

STATE

ZIP CODE

STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)

BUSINESS TELEPHONE NUMBER

CITY

COUNTY

STATE

ZIP CODE

Area Code (

)

5. Opening Date For Business In Tennessee

6. a. Sales and Use Tax No. _________________________________

____________________________________

b. Vending Machine Tax No. _______________________________

MONTH

DAY

YEAR

7. Registration of NEW vending machine business (enclose $2.00 ) ........................................................... $ ___________________

8. Registration of vending machines

A. Number of machines vending merchandise other than tobacco products ____________ X $1.00 ... $ ___________________

B. Number of machines vending tobacco products ____________ X $1.00 ............................................ $ ___________________

9. Total remittance enclosed (add Lines 7 and 8A and 8B) ................................................

Under penalties of perjury, I declare that the statements in this application are true and correct to the

best of my knowledge and belief. This application applies only to the specified business and location

listed hereon.

Authorized Signature & Title

FOR OFFICE

USE ONLY

Internet (3-01)

Form Gro-210 - Vending Machine Addendum 2001