Fillable Form 121 - Construction Project And General Contractor Registration printable pdf download

Form 121 - Construction Project And General Contractor Registration

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*0-0-701-099*

Wyoming Department of Revenue

Excise Tax Division

122 W. 25th Street, Herschler Bldg.

Cheyenne, Wyoming 82002-0110

Construction Project and General Contractor Registration

(

Please note that the general contractor must complete and remit this form to the above address with 15 days of the project award date)

Project Information:

1. Project Name______________________________________________________________________

2. Physical Address of Project:___________________________________________________________

3. Project Owner:_____________________________________________________________________

4. Total Project/Contract Amount:________________________________________________________

5. Anticipated Start Date:___________________ Anticipated Completion Date____________________

General Contractor Information:

6. General Contractor:_________________________________________FEIN/SS#________________

7. MailingAddress:____________________________________________________________________

8. City, State, Zip:____________________________________________________________________

9. Phone Number:________________________(800)Number______________Fax#________________

10. Contact Person:____________________________________________________________________

11. E-Mail Address:____________________________________________________________________

12. Will there be any non-resident subcontracts on this project? Yes____________ No______________

13. Describe your scope of work:__________________________________________________________

(remodel, renovation, new construction, office bldg Etc.)

Note: You must enclose a copy of the bid contractor that describes the scope of work you were hired to

perform.

We have been contracted by _____________________________________to be the General Contractor for the

project indentified above.

We Estimate the materials for this project will be: $________________________________________

I declare under penalty of perjury, the information provide above is correct and complete.

Authorized Signature:___________________________________ Title: _______________________

Printed Name:_________________________________________Date:________________________

(This form may be duplicated as necessary)

ETS Form 121 (revised 4/25/11)

Form 121 - Construction Project And General Contractor Registration

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