Voluntary Disclosure Questionnaire - Wyoming Department Of Revenue, Wyoming Voluntary Disclosure Agreement, Voluntary Disclosure Sales/use Tax License Application - Wyoming Department Of Revenue Page 5
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5Voluntary Disclosure
Department Use Only
Sales/Use Tax License Application
SIC:
RID:
Wyoming Department of Revenue
122 West 25th Street
License #:
Cheyenne, WY 82002-0110
Filing Freq:
*0-001*
Voluntary Agreement Type:
Nexus:
Voluntary Disclosure Applicants Only
1. Application Date:
2. Date this applicant started doing business in Wyoming:
3. Authorized Company Representative from Voluntary Disclosure Agreement:
4. Business Name or DBA:
5. Mailing Address:
Street or Box No.
City
State
Zip Code
6. Location Address:
Street
City
State
Zip Code
7. Is this business located within the boundaries of an incorporated city or town in Wyoming?
Yes
No
8. Does this company have a physical location in this state?
Yes
No
9. Does your company make deliveries of tangible personal property into this state with your own vehicles?
Yes
No
10. Do you have employees, sales representatives, or other agents working temporarily or permanently in the State
of Wyoming?
Yes
No
11. Internet E-mail Address____________________@_____________________________________________________________
12. Business Telephone Number: (
)_______-__________ (800)________-___________ Fax No.(
)________-___________
13. Authorized person to contact regarding sales/use tax matters _____________________________(
)________-___________
(Name)
(Phone Number)
14. Estimated monthly sales volume?
$_______________________
15. Describe specifically the type of products you sell, (Examples: auto parts, computers, vitamins) and/or services you provide,
(Examples: auto repair, computer repair) and the percent of the total sales each type represents [Example: (must equal 100%)
motel 50%, restaurant 30%, bar 20%]
(A)________________________
______%
(B)________________________
______%
(C)________________________
______%
(D)________________________
______%
16. What type of sales does this business make (check one) Wholesale_________Retail_________Both_________
17. Do you extend or arrange for the extension of consumer credit?
Yes
No
18. Please check one of the following to best describe your ownership:
*(Spousal ownership is considered a partnership)
(A)
Individual
(E)
Limited Partnership
(B)
Association/Club
(F)
Limited Liability Company
(C)
Partnership
(G)
Other (Explain)
(D)
Corporation 1)
2)
3)
(Corporate Name)
(Federal Identification Number)
(Date registered in WY)
Note: Corporations, limited partnerships, and limited liability companies must provide evidence of registration with the Wyoming
Secretary of State's Office (307) 777-7311. Corporations must attach a complete list of officers. Limited liability companies must
attach a complete list of members or managers. Licensing will be delayed until this information is provided.
19.
Complete this section by printing the name and social security number for the following individuals: Individual ownership: owner;
Partnership: all partners; Corporations: one major officer; Limited liability company and limited partnerships: one member
or manager. Signatures must be original.
A.
Print Name:
Signature:
SSN:
Address:
City
State
Zip Code:
B.
Print Name:
Signature:
SSN:
Address:
City
State
Zip Code:
C.
Print Name:
Signature:
SSN:
Address:
City
State
Zip Code:
D.
Print Name:
Signature:
SSN:
Address:
City
State
Zip Code:
By signing this application you agree you are licensing under W.S. 39-15-107.2 and agree to comply with all
20. SIGNATURES:
Wyoming Sales and Use Tax Statutes.
(Signature)
(Signature)
(Date)
(Date)
Don't Forget! Include the $60.00 non-refundable application fee. Obtain all signatures required.
Complete this application in its entirety and attach all required documentation.
Incomplete applications will be returned and licensing delayed.
Call Taxpayer Services at (307) 777-5200 for assistance in completing application.
ETS Form 001VD (Revised 03/01/04)
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