TVL-1                                            APPLICATION FOR 
  REV02-19                               TRANSIENT VENDOR LICENSE
This form should always be attached to form BUS-APP or BUS-RBL. Please type or print. Use blue or black ink to complete this form.
                                                   SECTION A:  BUSINESS IDENTIFICATION 
LEGAL BUSINESS NAME                                                                   FEIN (SSN For Sole Proprietor) 

DBA (Complete Schedule DBA for each additional DBA)

MAILING ADDRESS

CITY                                                                                  STATE                              ZIP

                                                   SECTION B: BONDING INFORMATION
SECURITY IN THE AMOUNT OF $500 MUST ACCOMPANY THIS APPLICATION. PLEASE CHECK TYPE OF SURETY TENDERED AND ATTACH TO FRONT OF FORM.
     SURETY BOND       CASH                        CERTIFIED CHECK          IRREVOCABLE LETTER OF CREDIT
                                                                                                                 AMOUNT DUE    $  500.00
NAME OF SURETY COMPANY OR BANK
ADDRESS OF SURETY COMPANY OR 
BANK

  CITY                                                                                                           STATE     ZIP
                            SECTION C: LOCATIONS AND DATES OF INTENDED SALES IN WEST VIRGINIA 
Notification must be provided to the West Virginia State Tax Department of ALL locations and dates of intended sales prior to entering the State.
If the number of locations exceeds three, please attach an additional page that lists the required information.  
     DATE OF                     DESCRIPTION 
     ACTIVITY                    OF ACTIVITY
     MMDDYYYY
1    PHYSICAL ADDRESS OF ACTIVITY

     CITY                                                                                                        STATE      ZIP

     DATE OF                     DESCRIPTION 
     ACTIVITY                    OF ACTIVITY
     MMDDYYYY
2    PHYSICAL ADDRESS OF ACTIVITY

     CITY                                                                                                        STATE      ZIP

     DATE OF                     DESCRIPTION 
     ACTIVITY                    OF ACTIVITY
     MMDDYYYY
3    PHYSICAL ADDRESS OF ACTIVITY

     CITY                                                                                                        STATE      ZIP
                                                              SECTION D: SIGNATURE
I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT.

SIGNATURE OF APPLICANT                                                                                           DATE

PRINT NAME                                                                     TITLE                             SSN
     TAX DEPARTMENT USE ONLY
     TRANSIENT VENDOR CERTIFICATE NUMBER           TAX IDENTIFICATION NUMBER

     ISSUE DATE        PERIOD                      WV BUS APP SURETY STATUS TAX STATUS
                                                                                      *B52201901W*
                                                                                      B 5   2                    2 0   1 9 0   1  W