Application For Permit/certificate - Wisconsin Department Of Revenue Page 2

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16. Provide the following information for sole proprietor, all general partners of a partnership (if only one general partner, please write "no other general

partners" in second column), all members of a limited liability company (if only one member, please write "no other members" in the second column) or the

principal officers of a corporation. If additional space is needed, attach a separate sheet.

NAME

SOCIAL

SECURITY

NUMBER

HOME

ADDRESS

CITY,

STATE &

ZIP

TITLE

17. If you have more than one (1) permanent location, indicate the business name and business address of each location. If additional space is needed, attach

a separate sheet.

TRADE OR

BUSINESS

NAME

BUSINESS

ADDRESS

CITY,

STATE &

ZIP

City

Village

City

CITY,

Village

City

Village

VILLAGE OR

Township

TOWNSHIP

Of:

COUNTY

18. Name and address of financial institution through which you will maintain your business checking account.

Name

Street Address

City

Account #

19. I declare under penalties of law that I have examined this information and to the best of my knowledge and belief, it is true, correct, and complete.

Signature (Must be signed by Proprietor, Partner, Member or Corporate Officer)

Social Security Number

Title

Date

(Required for Sole Proprietor)