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Tax Certification Statement 2013-2023
Tax obligations (including failure to file or
register) will cause the license application to be rejected. If additional space is needed, please use white 8½” x 11” paper.
Type or print all information requested.
1.
LICENSEE (APPLICANT) NAME
2.
3.
TRADE/FICTITIOUS NAME (IF ANY)
4.
LICENSED ADDRESS
5.
TYPE OF APPLICATION FILED
NEW
(STREET, RURUAL ROUTE, P.O. BOX NO.)
TRANSFER
OTHER
7.
NAME OF MANAGEMENT COMPANY
8.
TYPE OF ENTITY
9....
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