Ets Form 001vd - Voluntary Disclosure (Page 6 of 6) in pdf

Ets Form 001vd - Voluntary Disclosure Page 6

ETS Form 001VD (Revised 4/25/11)

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18. 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:_________

19. SIGNATURES: By signing this application you agree you are licensing under W.S.39-15-107.2 and agree to comply

with all Wyoming Sales and Use Tax Statutes.

___________________________________

Signature

___________________________________

Date

ETS Form 001VD(Revised 4/25/11)

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Ets Form 001vd - Voluntary Disclosure Page 6