DRUG-2
                       DRUG PARAPHERNALIA AFFIDAVIT
 REV02-19
Must be completed by applicant and each employee authorized to sell drug paraphernalia
                                                    SECTION A: BUSINESS IDENTIFICATION
 LEGAL BUSINESS NAME                                                                  FEIN (SSN For Sole Proprietor) 

1
 DBA (Complete Schedule DBA for each additional DBA)

 PHYSICAL ADDRESS OF BUSINESS NAMED ABOVE No Post Offi  ce Boxes

2
 CITY                                                                                 STATE                          ZIP

                                                    SECTION B: EMPLOYEE INFORMATION
SOCIAL SECURITY NUMBER DATE OF BIRTH (MMDDYYYY)     NAME

HOME ADDRESS

CITY                                                                                              STATE                 ZIP

                                                    SECTION C: SIGN AND NOTARIZE
I, THE UNDERSIGNED, SWEAR THAT I HAVE NEVER BEEN CONVICTED OF A DRUG-RELATED OFFENSE.

SIGNATURE OF APPLICANT                                                                DATE

      TAKEN, SUBSCRIBED, ACKNOWLEDGED AND 
      SWORN TO BEFORE ME ON THIS DATE :

            MY COMMISSION EXPIRES ON:

                       NOTARY PUBLIC                                                            (NOTARY SEAL)

            WEST VIRGINIA STATE TAX DEPARTMENT 
 MAIL TO:   TAX ACCOUNT ADMINISTRATION DIVISION 
            REGISTRATION & ACCOUNT CORRECTION UNIT
            PO BOX 2666
            CHARLESTON WV 25330-2666
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