Form Dr-1sn - Registration Application For Secondhand Dealers And Secondary Metals Recyclers Page 5
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5DR-1S
This page may be photocopied to provide additional location information.
R. 01/17
Business Partner Number: ______________________
Page 3
Location Information
Provide your Sales Tax Certificate Number for this location:
___ ___- ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - ___
This application* is for:
Secondhand Dealer
Mail-in Secondhand Precious Metals Dealer
Automated Kiosk Secondhand Dealer
Secondary Metals Recycler
Location Business Name __________________________________________________________________________________________________
Physical street address (Do not use PO Box) ________________________________________________________________________________
City__________________________________________County_________________________State ________________ZIP___________________
For this location enter the total number of licenses applied for: __________
*Include a $6 fee for each location and each license type.
Location Information
___ ___- ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - ___
Provide your Sales Tax Certificate Number for this location:
This application* is for:
Secondhand Dealer
Mail-in Secondhand Precious Metals Dealer
Automated Kiosk Secondhand Dealer
Secondary Metals Recycler
Location Business Name __________________________________________________________________________________________________
Physical street address (Do not use PO Box) ________________________________________________________________________________
City__________________________________________County_________________________State ________________ZIP___________________
For this location enter the total number of licenses applied for: __________
*Include a $6 fee for each location and each license type.
Location Information
___ ___- ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - ___
Provide your Sales Tax Certificate Number for this location:
This application* is for:
Secondhand Dealer
Mail-in Secondhand Precious Metals Dealer
Automated Kiosk Secondhand Dealer
Secondary Metals Recycler
Location Business Name __________________________________________________________________________________________________
Physical street address (Do not use PO Box) ________________________________________________________________________________
City__________________________________________County_________________________State ________________ZIP___________________
For this location enter the total number of licenses applied for: __________
*Include a $6 fee for each location and each license type.
Location Information
Provide your Sales Tax Certificate Number for this location:
___ ___- ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - ___
This application* is for:
Secondhand Dealer
Mail-in Secondhand Precious Metals Dealer
Automated Kiosk Secondhand Dealer
Secondary Metals Recycler
Location Business Name __________________________________________________________________________________________________
Physical street address (Do not use PO Box) ________________________________________________________________________________
City__________________________________________County_________________________State ________________ZIP___________________
For this location enter the total number of licenses applied for: __________
*Include a $6 fee for each location and each license type.
Location Information
___ ___- ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - ___
Provide your Sales Tax Certificate Number for this location:
This application* is for:
Secondhand Dealer
Mail-in Secondhand Precious Metals Dealer
Automated Kiosk Secondhand Dealer
Secondary Metals Recycler
Location Business Name __________________________________________________________________________________________________
Physical street address (Do not use PO Box) ________________________________________________________________________________
City__________________________________________County_________________________State ________________ZIP___________________
For this location enter the total number of licenses applied for: __________
*Include a $6 fee for each location and each license type.
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