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

                                                                                                  _____________________________________________________________
                                                         NameTEST CORPORATION 1                                                                                                        Letter Id:    L0611598336
                                                                                                  1001_____________________________________________________________           LEE ST E Issued:            04/02/2019
                                                                       CHARLESTONAddressWV  25301-1725
                                                                                                  _____________________________________________________________
             City                                                                                     State    Zip
                                                                                                             
                                                WEST VIRGINIA DEPARTMENT OF REVENUE  
      WV/TLM                                    TELEMARKETER REGISTRATION FORM
      REV02-19                                                                           Update your information online at  mytaxes.wvtax.gov.
      Delays issuing your 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.
      If you are not already registered, attach this to a completed WV BUSAPP. NOTE: This form has been redesigned. To avoid delays in the processing of this form, DO NOT use older forms.
                                                                               SECTION 1:  CONTACT INFORMATION
 FEIN 
 (SSN for Sole Proprietor)                                                                                                                                                             AMOUNT DUE            $    250.00
  LEGAL NAME                                                                                                    OTHER BUSINESS NAME

  STREET ADDRESS (No PO Boxes)                                                                                  CITY                                                                                STATE      ZIP

  TELEPHONE                  FAX                                                                        EMAIL                                                                            WEBSITE

                                                                               SECTION 2:  LOCATION INFORMATION
Please provide information for the locations from which sales will be solicited, if different from above. If you have more than 3 locations, use mytaxes.wvtax.gov   
            STREET ADDRESS (No PO Boxes)                                                                CITY                                                                             STATE   ZIP           TELEPHONE
 1

 2

 3
                                                SECTION 3:  FINANCIAL INSTITUTION INFORMATION
Please provide the following information for the two principle financial institutions where banking or other monetary transactions are conducted by the seller:    
       FINANCIAL INSTITUTION ROUTING #            STREET ADDRESS                                                                                                 CITY                                  STATE        ZIP
1

2
                                                                                         SECTION 4:  SURETY BOND

      SURETY BOND          GOVERNMENT BOND                                               CASH                 LETTER OF CREDIT                                                         APPLICATION FOR EXEMPTION FROM SURETY
                                                                                                                                                                                       REQUIREMENT
                                                                                                      SECTION 5:  SIGNATURE
Under penalty of perjury, I declare that I have examined this application, accompanying documents, and statements, and to the best of my knowledge and belief, it is true, correct and complete.  

SIGNATURE                                       PRINT NAME                                                    TITLE                                                                                       DATE

      MAIL TO:    WEST VIRGINIA STATE TAX DEPARTMENT  
                  Tax Account Administration Div  
                  P.O. Box 2666   
                  Charleston, WV 25330-2666  
      FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297  
      For more information visit our web site at: www.tax.wv.gov  
      File online at https://mytaxes.wvtax.gov  
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  WV/TLM              WEST VIRGINIA DEPARTMENT OF REVENUE                                                                                                                              FEIN
  CONTINUED           TELEMARKETER REGISTRATION FORM
                                         SECTION 6:  OWNER AND OFFICER INFORMATION
    NAME                                                                                          DATE OF BIRTH                                                                                          SSN

   OFFICE HELD                             EMAIL                                                                                                                                                         PHONE
1

    STREET ADDRESS                                                                                 CITY                                                                                                  STATE           ZIP/POSTAL CODE

    NAME                                                                                          DATE OF BIRTH                                                                                          SSN

   OFFICE HELD                             EMAIL                                                                                                                                                         PHONE
2

    STREET ADDRESS                                                                                 CITY                                                                                                  STATE           ZIP/POSTAL CODE

    NAME                                                                                          DATE OF BIRTH                                                                                          SSN

   OFFICE HELD                             EMAIL                                                                                                                                                         PHONE
3

    STREET ADDRESS                                                                                 CITY                                                                                                  STATE           ZIP/POSTAL CODE

  COMPLETE FOR ALL OFFICERS LISTED ABOVE                                                                                                                                               OWNER/OFFICER 1 OWNER/OFFICER 2 OWNER/OFFICER 3

  OWNERSHIP INTEREST ..................................................................................................................................................                YES NO          YES     NO      YES                        NO
  HAS THE INDIVIDUAL OR BUSINESS FILED FOR BANKRUPTCY, BEEN ADJUDGED BANKRUPT, OR
   REORGANIZED BECAUSE OF INSOLVENCY WITHIN THE LAST SEVEN YEAR?  (If answer is Yes, see Section                                                                                       YES NO          YES     NO      YES                        NO
   7 for further details) .............................................................................................................................................................
  HAS THE INDIVIDUAL BEEN CONVICTED, OR PLED GUILTY TO, OR IS BEING PROSECUTED BY                                                                                                      YES NO          YES     NO      YES                        NO
   INDICTMENT FOR, RACKETEERING OR ANY VIOLATIONS OF STATE OR FEDERAL SECURITY LAWS?................
                                         SECTION 7:  SUPPLEMENTAL INFORMATION
  Supplemental information regarding question concerning bankruptcy, racketeering and security law violations:
                                         ACTION 1                                 ACTION 2                                                                                                                     ACTION 3
         NAME
  DATE OF CONVICTION
  JUDGEMENT OR ORDER
         MMDDYYYY
  GOVERNMENT AGENCY
  WHICH BROUGHT ACTION

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