R-16019 (5/08) CR1
                                      Application for Louisiana Revenue Account Number
                                      P.O. Box 201                                                                 For office use only.
                                      Baton Rouge, LA 70821-0201
                                      (225) 219-7318
Date of application
 1.      A. Sales/ Use                                                 B.     ■ Withholding                                F.   ■  Other                   
              ■  Louisiana General Sales Tax                           C.     ■ Vehicle Rental Excise                           _________________________ 
   ■               Statewide Hotel/Motel                               D.     ■ Severance                                        
     ■             Jefferson Parish Hotel/Motel                        E.   Oil and Gas Classification                          _________________________
   ■               Orleans Parish Hotel/Motel                                 ■  Taxpayer Only 
              ■    Orleans Parish Restaurant                                  ■  Producer Only                                  _________________________
   ■               N.O. Airport Food Establishments                           ■     Producer/Taxpayer
   ■               Motor Vehicle Lessors/Rentors
2.       Reason for applying            A.    ■   Started new business                C.       ■   Other (specify) 
                                        B.    ■   Purchased ongoing business: Name of previous owner 
3.       Indicate the account number you use for each tax filed with the Louisiana Department of Revenue.
         LA Corp. Tax Number            None  ■          LA Sales Tax Number          None  ■              LA Excise Taxes Number          None  ■

         LA Withholding Tax Number  None      ■          LA Severance Tax Number   None         ■          LA Natural Resource Number  None■ 

4.       A.   Legal name(s)
         B.   Trade name of business                                                                               Telephone    (       )  __________________
5.       A.   Business location address (NO P.O. Box or General Delivery)
         B.   City and state                                                                                                        C.  ZIP
 6.      A.   Address for receiving tax forms and correspondence (If same location, write “same”.) 
         B.                                                       C.                  D.       (       )                   E.  ■       Additional mailing 
                               City and State                                 ZIP                        Telephone               address(es) attached
7.       Type of organization:  A.    Individual■ B.    ■ Partnership        C. ■ Corporation    D. ■  Governmental   E.   Nonprofit■          F.  ■Other
8.       U.S. NAICS Code                                          9.   Federal Employer                                                     None    ■
         (required)                                                    ID Number 
10.  If sole owner (individual):  Name                                                                              SSN
         Home address                                                                                               Telephone  (       )
11.  If corporation or partner-      Name                                             Title
         ship: name, title, Social                                                                                  SSN
         Security Number, home       Address                                                                                     (       )
         address, and telephone                                                                                     Telephone              _________________ 
         number of officers or       Name                                             Title
         partners                                                                                                   SSN
                                     Address                                                                        Telephone    (       ) _________________
12.  A.       Louisiana Charter Number (if known) _________________________            B.  State of incorporation (if not Louisiana) ___________________
13.  Permits -Sellers of liquor, beer, or wine (wholesale or retail), must obtain a permit from the Office of Alcohol and Tobacco Control. A permit from 
         the Louisiana State Police Gaming Division must be obtained by sellers of lottery tickets or operators of video poker games. Indicate permit 
         number(s) that you currently hold.
         A.   Lottery Permit Number                                                     B.  Expiration Month/Year _______________________________
              Alcohol Permit Number                                                            Expiration Month/Year  _______________________________
              VPG Permit Number                                                                Expiration Month/Year ___________________________
                                                                                                            Mo.  Day   Yr. Domestic    Foreign Fiscal Month
14.  A.  Corporation Income/Franchise: Date charter filed with Louisiana Secretary of State                                B.                  C.  
15.  Sales or Use Tax: Date business begins       sales operation sfrom this location 
16.  Withholding Tax: (See instructions.) Select filing frequency.  ■ quarterly   ■ monthly   ■semi-monthly
17.      Severance Tax: Select filing frequency.  ■ quarterly   ■ monthly    45-day■
18.  Description of business: (required) 
                                          Signature of applicant                                           Title
I affirm that the information given 
on this application is true and  
correct.                                  Signature of preparer                                            Date (mm/dd/yyyy)

                                                                                                                                                   1500