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Government of Puerto Rico

Serial Number

Form AS 2914.1 C

DEPARTMENT OF THE TREASURY

Rev. Aug 30 11

APPLICATION TO ADD A NEW LOCATION OR ACTIVITY

TO A MERCHANT REGISTERED IN THE MERCHANTS’ REGISTRY

PART I – INFORMATION OF MERCHANT’S PRINCIPAL OFFICE

Receipt Stamp

In order to process your application, you shall complete all boxes of this Part I.

1. Legal name of the corporation, partnership, individual owner (name, initial, last name) or other

2. Social security or employer identification number

First seven digits of your Merchant's Registration Number:

0 0 0 0

PART II - NEW LOCATION OR ACTIVITY

4. Trade name or "DBA"

5. Type of registration certificate requested:(Check one):

Merchant

Mobile business

Temporary business

Exhibitor

(

)

If you checked Temporary Business or Exhibitor, indicate:

From:

Month

Year

To:

Day

Month

Year

Day

Ext.

6. Telephone

7. Will you sell tangible personal property?

Yes

8. Description of tangible

personal property

9. Location's physical address

(Urbanization or Building, Number or Apartment, Street)

Municipality / City

Zip Code

Country

State

10. Description of the activity

12. Beginning date of operations:

11. North American Industry

13. Indicate if you are a:

Reseller

Manufacturing Plant

Classification System (NAICS)

Day

Month

Year

(If you are interested in requesting an Exemption Certificate, refer to Form

AS 2914.1 D)

14. Aggregate business volume, estimated or projected, at the end of the current calendar year: $

NOTIFICATION REGARDING THE IVU LOTO OVERSIGHT PROGRAM

Once you receive your Merchant's Registration Certificate, you are required to register for purposes of the IVU Loto oversight program through the website

or by calling (787) 200-7900 Option Number 4. (It does not apply to merchants registered as temporary businesses or exhibitors). For additional details, refer to the back of this form.

OATH

I hereby declare under penalties of perjury that this application has been examined by me, and that to the best of my knowledge and belief, all the information provided herein is

true, correct and complete. I also agree to notify the Secretary of the Treasury of any change in the information provided on this application, within 30 days of the change or event.

The declaration of the person that prepares this application (except the merchant) is with respect to the available information, and such information has been verified.

Merchant's name

Merchant's signature

Title

Date

Name of duly authorized agent

Signature of duly authorized agent

Date

Social security or employer identification number

Address

Telephone

TO BE COMPLETED BY THE DEPARTMENT OF THE TREASURY

After evaluating this application, I certify that it is complete in all of its parts and that the information provided herein is presumed to be true. Nevertheless, the Department of the

Treasury reserves the right to conduct any future investigation to verify the information.

Date

Employee's name

Employee's signature

District

Retention: Six (6) years.