Form As 2914.1 - Application For Merchant'S Registration Certificate

Form As 2914.1 - Application For Merchant'S Registration Certificate - 2011 Page 2

Page 2

Form AS 2914.1

Rev. Aug 30 11

CONTINUED PART II (LOCATIONS / ACTIVITIES)

19. Description of the activity

20. North American Industry

21. Beginning date of operations:

22. Indicate if you are a:

Reseller

Manufacturing Plant

Day

Month

Year

Classification System (NAICS)

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

AS 2914.1 D)

23. Business volume, estimated or projected, at the end of the current calendar year: $

PART III - PERSONS HAVING INTEREST IN THE BUSINESS

24. Indicate the information for each owner, partner, shareholder or any other person owning 50% or more interest in the business:

Ownership percentage

24a. Name

Title

Social security or employer identification number

If your business provides services, do you own 50% or more interest in another business?

Yes

No. If "Yes", indicate the following information for the other business:

Name

Social security or employer identification number

Ownership percentage

24b. Name

Title

Social security or employer identification number

If your business pvovides services, do you own 50% or more interest in another business?

Yes

No. If "Yes", indicate the following information for the other business:

Name

Social security or employer identification number

NOTIFICATION REGARDING THE IVU LOTO OVERSIGTH 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 instructions 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 signature

Merchant's name

Title

Date

Signature of duly authorized agent

Name of duly authorized agent

Date

Address

Telephone

Social security or employer identification number

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.

Employee's name

Employee's signature

Date

District

Confirmation number

Retention: Six (6) years.