*0-0-701-099*
                                                                                                    *0-0-701-099*
            Wyoming Department of Revenue 
                   Excise Tax Division 
                   122 West 25th Street, Suite E301 
                   Herschler Bldg East
                   Cheyenne, Wyoming 82002
                   http://revenue.wyo.gov 
                     Construction Project and General Contractor Registration 

Please note that the general contractor must complete and remit this form to the above address within 15 
Days of the project start date. 

Project Information: 

1. Project Name____________________________________________________________________________
2. Physical Address of Project:_________________________________________________________________
3. Project Owner:___________________________________________________________________________
4. Total Project/Contract Amount:______________________________________________________________
5. Anticipated Start Date:___________________ Anticipated Completion Date:_________________________

General Contractor Information: 

6. General Contractor Legal Name:__________________________________FEIN/SS#__________________
7. MailingAddress:__________________________________________________________________________
8. City, State, Zip:__________________________________________________________________________
9. Phone Number:__________________________(800)Number_________________Fax#_________________
10.Contact Person:___________________________________________________________________________
11.E-Mail Address:__________________________________________________________________________
12.Will there be any non-resident subcontracts on this project?   Yes________________No_________________
13.Describe your scope of work:________________________________________________________________
                                         (remodel, renovation, new construction, office bldg. etc.) 

Note: You must enclose a copy of the bid that describes the scope of work you were contracted to 
perform.) 

We have been contracted by:______________________________________to be the General Contractor for 
the project identified above. 

We estimate the materials for this project will be: $_______________________________________ 

I declare under penalty of perjury m the information provided above is correct and complete. 

Authorized Signature:_______________________________________Title:__________________________ 

Printed Name:_____________________________________________Date:__________________________ 

ETS from 701 revised 9/14/16       (This form may be duplicated as necessary)