Sales And Use Tax Payers Only Merchandise Vending Operators Request Form
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1MAIL OR BRING TO:
Miscellaneous Tax Section
1816 West 7th Street
P. O. Box 896 Room 2240
Little Rock, AR 72203-0896
Phone (501) 682-7187
Fax (501) 682-1103
DFA Web Site -
(FOR OPTION 1& 2 ONLY)
SALES AND USE TAX PAYERS ONLY
MERCHANDISE VENDING OPERATORS REQUEST
*(OPTION 2 REQUIRED)
Name:
Sales Tax Permit:
DBA:
Sales Tax Vendors Number:
Mailing Address:
Fed I.D.\Soc. Sec. No.
City:
Bus. Phone: (
)
State:
Zip:
Eme. Phone: (
)
Business Location:
Number of Stamps Requested
CHECK ONE
□
NEW ORDER
□
REORDER
□
CHARITY:
(IF CHARITY IS CHECKED THEN GIVE NAMES, ADDRESSES AND PHONE NUMBERS OF CHARITIES IN COMMENTS SECTION BELOW)
(SIGNATURE OF PERSON ORDERING)
(DATE)
COMMENTS:
MISCELLANEOUS TAX SECTON
NUMBER OF STAMPS ISSUED:
Certified No.
Date of Issuance
Signature of Investigator
Date
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