STATE OF WEST VIRGINIA
          State Tax Department, Tax Account Administration Div
          P.O. Box 2666
          Charleston, WV 25330-2666

          Name
          Address
          City                                                         State                         Zip

  BUS-RBL                                                REISSUANCE OF BUSINESS 
  Rev 02-21                                        REGISTRATION CERTIFICATE
       Go to mytaxes.wvtax.gov.   to request a duplicate license, update your information, or change DBA/trade names not printed on your business license from the WV Tax Department. 
  Delays issuing your business license may occur if you fail to submit ALL the pages of this form, fail to complete all required sections, or do not include all required supporting documentation. 
                         Taxpayers required to file electronically will no longer receive returns for the tax types subject to the mandatory requirement  by mail. 
                         SECTION A: REASON FOR SUBMITTING THIS APPLICATION Choose all that apply. 
  CHANGE LEGAL NAME           CHANGE DBA                          ADD DBA                             CHANGE LOCATION             ADD/REMOVE BUSINESS ACTIVITY
  Complete lines 1, 2, 7      Complete lines 1, 3,7               Complete lines 1, 3, 7              Complete lines 1, 4, 7      Complete lines 1, 6, 7
                                                             SECTION B: BUSINESS IDENTIFICATION 
1 FEIN                                        SSN                                                                  WV BUSINESS 
                                              For Sole Proprietor                                                  REGISTRATION ACCOUNT #
  LEGAL NAME currently on registration (for other locations, send additional BUS-RBL)    NEW LEGAL BUSINESS NAME
2

  DBA currently printed                                                                  DBA TO ADD TO LICENSE 
3 on license to be                                                                       For DBA/Trade names not on 
  removed                                                                                license, complete Schedule DBA 
  LOCATION CURRENTLY ON REGISTRATION                                                     NEW LOCATION (NO PO BOXES)

  ADDRESS LINE 2                              UNIT TYPE                UNIT NUMBER       ADDRESS LINE 2                                     UNIT TYPE                 UNIT NUMBER
4

  CITY                                        STATE      ZIP                             CITY                                               STATE        ZIP

  MAILING ADDRESS CURRENTLY ON ACCOUNT                                                   NEW MAILING ADDRESS

  ADDRESS LINE 2                              UNIT TYPE                UNIT NUMBER       ADDRESS LINE 2                                     UNIT TYPE                 UNIT NUMBER
5

  CITY                                        STATE      ZIP                             CITY                                               STATE        ZIP

  ADD OR REMOVE  Add Remove                   Add Remove                         Add Remove                  Add Remove                     Add Remove
6 SPECIAL LICENSE                                        DRUG                            COLLECTION                           TRANSIENT                  EMPLOYMENT 
  CHOOSE ALL             TOBACCO                         PARAPHERNALIA                   AGENCY                               VENDOR                     AGENCY
       THAT APPLY
                                              IF EXEMPT, 
  AMOUNT DUE            $  30.00                   SELECT              GOVERNMENT                    AGRICULTURE              CHARITABLE                    RELIGIOUS 
                                                         ONE:          AGENCY                        OR FARMING               ORGANIZATION                  ORGANIZATION

7
  SIGNATURE                                                                              PRINT NAME

  EMAIL                                                                                  PHONE                                                              DATE
  MAIL TO:         WEST VIRGINIA STATE TAX DEPARTMENT 
                   TAX ACCOUNT ADMINISTRATION DIVISION 
                   REGISTRATION & ACCOUNT CORRECTION UNIT
                   PO BOX 2666
                   CHARLESTON WV 25330-2666                                                                        *B51202101W*
  FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297
  For more information visit our web site at: tax.wv.gov                                                           B51202101W