Form 001vd - Sales And Use Tax License Application Voluntary Disclosure Page 6
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618. 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
Signature
Date
Date
ETS Form 001VD(Revised 4/25/11)
Page 2 of 2
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