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.y <br />i <br />V ARKANSAS <br />Department of Finance and Administration <br />z <br />Sales and Use Tax Section <br />P. O. Box 1272, Little Rock, AR 72203-1272 (501) 682-7104 <br />For Office Use <br />Application for Sales and Use Tax Permit <br />Applicants must answer ALL of the requested information fields in order to receive a permit for business in Arkansas. <br />1 • Q -Q �D CgtpplQt �fo-rm i BLUE or BLACK ink ONLY <br />1. <br />Na usiness BA)2. <br />Co orate Name or Partnership Name <br />3. 00 e `l\Cc*,n .L-br:e f— <br />Location - Street Address of Business (Not P. O. Box) <br />4. <br />Lo ation - Street Address of Business (if additional space is needed) !- <br />5. P- u �� -7a. &D '�' <br />City ST Zip Code County (if qn Arkansas) <br />6. � -� o - G9 ?-a *aD <br />Business Location Phone Number Ext <br />Mailing Address (if different from Location Address) <br />8. <br />Mailing Address (if additional space is needed) <br />9. <br />City ST Zip Code <br />10. <br />Owner/Home Office Phone Number Ext <br />11. I I K Ouc t04o <br />Federal I ,(I L� <br />Nam of er/Officer oPartner First MI Last <br />1 <br />r <br />Title r <br />Do L� . <br />Mailing Address of Owner <br />Maili g Address of gwner <br />City ST Zip Code SSN <br />13. Orv, a-, <br />Name of Owner/Officer or Partner First Last <br />L��o,�.a or <br />Title <br />0 e . I Yea;n <br />Mailing Address of Owner <br />Mail ng Address o Owner <br />City ST Zip Code SS <br />&t <br />14. List exactly the products sold or type of service rendered. U'( 9OU-t' t-'0- e- c-'+�U, <br />Form ST-1 (R 07/2006) <br />