Form Ap-201-3 - Texas Application For Sales Tax Permit, Use Tax Permit And/or Telecommunications Infrastructure Fund Assessment Set-Up - 2005 Page 2

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AP-201-4

(Rev.7-05/9)

TEXAS APPLICATION FOR SALES TAX PERMIT,

USE TAX PERMIT AND/OR

• TYPE OR PRINT

TELECOMMUNICATIONS INFRASTRUCTURE FUND ASSESSMENT SET-UP

Page 2

• Do NOT write in shaded areas.

18. Legal name of entity (Same as Item 1 OR Item 5)

19. Is your business located outside Texas? ........................................................................................................................................

YES

If "YES," skip to Item 28

20. Business location name and address (Attach additional sheets for each additional location.)

Business location name

Street and number (Do not use P.O. Box. or rural route)

City

State

ZIP code

County

Physical location (If business location address is a rural route and box number, provide directions)

Business location phone

21. Is your business located inside the boundaries of an incorporated city? ......................................................................................

YES

If "YES," indicate city (You may need to contact your local city/county planning offices for assistance in determining the city taxing jurisdiction for your

business location address entered in Item 20.)

Answer the questions below about the above location by checking "YES" or "NO."

O/L

22. Is your business located inside a transit authority? .....................................................................................................................

YES

23. Is your business located inside a special purpose district (SPD)? ................................................................................................

YES

24. Will you deliver in your own vehicles, provide taxable services, or have sales/service representatives going from this location to customers located in:

another city? ...................................................................................................................................................................................

YES

another county? .............................................................................................................................................................................

YES

TRANSIT LISTINGS

another transit authority? ..............................................................................................................................................................

YES

SPD LISTINGS

another SPD? .................................................................................................................................................................................

YES

25. Will you ship from this location to other customers via common carrier? ......................................................................................

YES

26. Are you a seller with no established place of business selling at a temporary location (trade show, event, or door to door)? .....

YES

27. Will you have out-of-state suppliers shipping taxable items directly to customers' locations in Texas? ........................................

YES

28. If you sell fireworks, are you a .................

Distributor .......................

Jobber .......................

Manufacturer .......................

Retailer

29. Do you sell, lease, or rent off-road, heavy duty diesel powered equipment? ............................................................................

YES

30. Will you sell any type of alcoholic beverages? ............................................................................................................................

YES

If "YES," indicate the type of permit you will hold: .....................................................................................

mixed beverage

beer and wine

31. Will you sell memberships to a health spa? ..................................................................................................................................

YES

If "YES," a copy of your SOS certificate of registration must accompany this application.

32. Check the box that best represents your anticipated quarterly state sales tax collections:

less than $250

$250-$1,500

greater than $1,500

month

day

year

33. Enter the date of the first business operation in the above location that is subject to sales or use tax, or

the date you plan to start such business operation. (Date cannot be more than 90 days in the future.) ....................................

34. Is your business operated all year? ..............................................................................................................................................

YES

If "NO," list the months you will operate.

35. Brief description of your business activities for this location, and the primary products or services to be sold.

SIC/NAICS

36. Will you be required to report interest earned on sales tax? (See "Specific Instructions") .......................................................

YES

37. Are you located out of state with representation in Texas? ........................................................................................................

YES

If "YES," complete Item 38. If "NO," skip to Item 39.

38. List names and addresses of all representatives, agents, salespersons, canvassers, or solicitors in Texas. (Attach additional sheets, if necessary.)

Name (First, middle initial, last)

Street

City

State

ZIP code

T X

39. Location of all distribution points, warehouses, or offices in Texas (Attach additional sheets, if necessary.)

Street

City

State

ZIP code

T X