Webster           Parish          Sales           Use       Tax      Commission                                                               wwwwebsiersalestaXOre

                                       REGISTRATION                    CERTIFICATE                   APPLICATION
   1128 HomerRoad     3    OP  Box357      MiudenLA035771058           d  Phone   318 8948377        3 Fax 318 4089377          4 Email   ersalestaxocgwpstanCwebs
For    Webster Parish         Webster Parish       Webster Parish         Town of         Town of        City of        City of     Town of      Town of        Village of
       School Board           Law Enforcement         Police Jury            Sibley    Cotton Valley     Minden     Springhill      Cullen       Sarepta        Dixie Inn
                                                                       1     Date of Application                                  FOR     OFFICE     USE      ONLY
                                                                             YearDayMonth
                                                                                                                             Date Issued

                                                                       2     LA Sales Tau Number             None            No Issued

                   DO NO7 WRITE IN THIS SPACE                                                                                APPLY     ONLINE    AT      LAOTACOM
3   Reason for Applying           A    Started New Business                       Other Specify
                                  B    Purchased Going Business        Name of Previous Owner
4   A    Business  Name    as it Appears to the Public D8A
    B    Business  Name    if Other Than Above Legal Name
    C    Legal Names       of Owners                                                                              D     Email Address
    E    Parish In Which                                       F  Business Phone                                  G     Business  Fax
         Business  is Located                                     Number                                                Number
5  A     Business  Location   Address Steet   Road or Highway                                                                        Inside     Outside City LimNs
         NOT   PO  Box   or Gen   Del                                                                                                         Circle One
    8 ityC  dna   teaSt                                                                                                 CZip     Code
6  A     Address for Receiving Tar Forms     and Corcespondence
         If Same as Location     Write Same
    B    Cily and State                                                                                                 C Zip    Code
7  Type  of Organization           A      Individual     B       Partnership      C    Corporation       D        Governmental       E        NonProfit       F    Other
8   Federal  Standard                                          9  Federal Employer                                                                       None
    Industrial Code   if Known                                    ID Number
10  If Sole Owner Individual          Name                                                                              SSN
    Home Address                                                                                                        Phone
11  If Corporation or         Name                                                          nne                         SSN
   Partnership    Name        nderess                                                                                   Phone
   Title Soa Sec No           Name                                                          rne                         SSN
   Home Address and           ndarass                                                                                   Phone
   PhOnO NOOf                 Name                                                          rne                         SSN
   Officers    or Partners    naas                                                                                      Phone
12 State of Incorporation   if not Louisiana
13 Describe in    detail your business type of sales activity or service you    perform

14 First Date  Sales Will  Be  Made   From This Location         Mont                                        Day                             Year
                               I AGREETO NOTIFYTHE SALESTAX               OFFICE WHEN ANY       OFTHIS INFORMATION           CHANGES
                                                            IMPORTANT PLEASE READ CAREPULLY
I understand that giving false or fraudulent information of this application is a violation of state tax law RS   332845     and may resutt in criminal prosecution
To the best of my knowledge the   intormation provided above   is correct I FURTHER    UNDERSTAND
   That state and local laws   require that I collect account for report and    remit the tau due and
   That failure to file  a report and pay what is due on a timely basis resulis in penalry and interest     being imposed by law and   continued delinquency results   in
   an assessment      negligence penalties  and possible legal   aclion
   That state  law provides Criminal   Penalties under   La RS 332845        2846 tor 1 failure to file a return or the filing of a false or fraudulent return and
   2 failure to collect    account for or pay over any tau  penalty or interest under any   provision    of local sales and use tax law
   Thatan    owner partner or    responsible corporate officer mavbe held sonalpyliable for sales        cesta    which have been collected   andnot remitted

X                                                                                                                 X
Signehre of Applicant Owner Pertner or Responsible Corporate Oflicer                 71t1e                              Signature of Preparer H DNfarent from Applicant

                                                            OriginalWHI7E    KeepForYourRewrtlsVELLOW