Form Wv/brt-803 - Application For Transient Vendor License
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1West Virginia State Tax Department
WV/BRT-803
Rev. 12/14
Office of Business Registration
This Form Is To Be Used By A
Please Type Or Print.
Transient Vendor As A Supplement To
P. O. Box 2666
Use Blue Or Black Ink
WV/BRT-8.01 (Application For
To Complete This Form
Charleston, West Virginia 25330-2666
Business Certificate)
Application For Transient Vendor License
1.
Transient Vendor Certificate Number
2. Tax Identification Number
West Virginia
State Tax
3.
Issue Date
4.
Period
5. WV/Bus-App
6.
Surety Status
Department
USE
7.
Vendor’s Name
8.
Tax Status
ONLY
9.
Trade Name
10. Name Under Which Certificate Is To Be Issued (Trade Name, Fictitious Name or Legal Name)
Address
City
County
State
Zip Code
11. Security in the amount of $500 must accompany this application.
Please check type of surety tendered and attach to front of form.
NAME AND ADDRESS OF SURETY COMPANY OR BANK
r
r
Irrevocable Letter of Credit
Surety Bond
r
Cash
r
Certified Check
12. Locations and dates of intended sales in West Virginia for year 20 ____ . If additional space is required, please attach additional sheet of paper with list
of locations.
ACTIVITY
DATE OF ACTIVITY
a. Street Address
City
State
County
Zip Code
b. Street Address
City
State
County
Zip Code
c. Street Address
City
State
County
Zip Code
d. Street Address
City
State
County
Zip Code
Notification must be provided to the West Virginia State Tax Department of All Locations and dates of intended sales prior to entering the State.
13. I certify that the information provided on this form is true and correct.
PRINT NAME
SOCIAL SECURITY NUMBER
TITLE
SIGNATURE
TELEPHONE NUMBER
DATE
See Reverse Side For Important Information
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