STATE OF RHODE ISLAND DIVISION OF TAXATION RETAIL SALES PERMIT 
                              ONE CAPITOL HILL - PROVIDENCE, RI 02908    RENEWAL APPLICATION

                                                                         Due on or before  
                                                                         February 1, 2021
NAME

ADDRESS                                                 STREN
                                                                         16127099990101
CITY, STATE & ZIP CODE                                                   TAX YEAR 
                                                                      JULY  1,  2021  -  JUNE  30,  2022 
SIGNATURE OF OWNER, PARTNER OR AUTHORIZED AGENT                           
                                                                      Sales Tax Renewal Fee $10.00 
TITLE
                                                                          
                                                                      Please mail this form with remittance separately. 
 FORM STREN REVD 01/2021 DATE                                            Do not mail with a return. 
                                                                          
                         TAXPAYER IDENTIFICATION NUMBER               Mail this form and remittance payable to: 
                                                                      Rhode Island Division of Taxation 
                                                                         One Capitol Hill 
                                                                         Providence, RI 02908