Form As 2914.1 - Application For Merchant'S Registration Certificate - 2011 Page 3

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Schedule AS 2914.1
LOCATIONS
Rev. Aug 30 11
Legal name of the corporation, partnership, individual owner (name, initial, last name) or other
Use this Schedule if you own more locations than the spaces provided in Part II of the Application for Merchant's Registration Certificate and Exemption Certificate (Form AS 2914.1).
1. Trade name or "DBA"
2. Type of registration certificate requested (Check one):
Merchant
Mobile business
Temporary business
Exhibitor
If you checked Temporary Business or Exhibitor, indicate: (From:
Day
To:
Day
Month
)
Month
Year
Year
Ext.
3. Telephone
4. Will you sell tangible personal property?
Yes
No
5. Description of tangible
personal property
6. Physical address
(Urbanization or Building, Number or Apartment, Street)
Zip Code
Country
Municipality / City
State
7. Description of the activity
8. North American Industry
9. Beginning date of operations:
10. 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)
11. Business volume, estimated or projected, at the end of the current calendar year: $
,
,
.
1. Trade name or "DBA"
2. Type of registration certificate requested (Check one):
Merchant
Mobile business
Temporary business
Exhibitor
Month
Month
If you checked Temporary Business or Exhibitor, indicate: (From:
Day
Year
To:
Day
Year
)
3. Telephone
Ext.
4. Will you sell tangible personal property?
Yes
No
5. Description of tangible
personal property
6. Physical address
(Urbanization or Building, Number or Apartment, Street)
Country
Zip Code
Municipality / City
State
7. Description of the activity
8. North American Industry
9. Beginning date of operations:
10. 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)
11. Business volume, estimated or projected, at the end of the current calendar year: $
,
,
.
Retention: Six (6) years.

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