FT 545 (05/15/2013)
CITY
Purpose: Use this form to apply for the capability to file the Virginia wholesale sales tax activity information electronically using
Xerox Company, the Virginia-approved vendor.
Instructions: Print in ink or type to complete form. Fax completed form to (804)367-0233.
DISCLAIMER
TRANSMISSION FORMAT INFORMATION
APPLICANT INFORMATION
CHECK THE BOX WHICH INDICATES HOW YOU WILL TRANSMIT ELECTRONIC DATA
CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I
understand that knowingly making a false statement on this form is a criminal violation.
The Xerox system is for the use of authorized clients only. To protect the computer network system from unauthorized use and to ensure the computer
network system is functioning properly, system administrators monitor this system. Individuals using the computer network system without
authorization, or in excess of their authorization, are subject to having all their activity on this computer network system monitored and recorded by
system personnel. Anyone using this computer network system expressly consents to such monitoring and is advised that if such monitoring reveals
possible conduct of criminal activity, system personnel may provide the evidence of such activity to law enforcement officers. Access is restricted to
authorized users only. Unauthorized access is a violation of state, federal, civil, and criminal laws.
XEROX COMPANY USE ONLY
COMPANY NAME FEIN
VIRGINIA WHOLESALE SALES TAX
ELECTRONIC/INTERNET FILING
APPLICATION
WHOLESALE SALES TAX LICENSE NUMBER
ZIP CODESTATEBUSINESS STREET ADDRESS
CONTACT PERSON NAME
EMAIL ADDRESS
ASCII FLAT FILE INTERNET (WEB)
AUTHORIZED REPRESENTATIVE NAME (print) AUTHORIZED REPRESENTATIVE SIGNATURE DATE (mm/dd/yyyy)
WH ACCOUNT IDENTIFICATION
TELEPHONE NUMBER
