Fillable BC 2014 PAYMENT SUMMARY OWNERSHIP Provide Corporate Officer (The Tulalip Tribes)

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BC 2014 PAYMENT SUMMARY OWNERSHIP Provide Corporate Officer (The Tulalip Tribes)

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The BC 2014 PAYMENT SUMMARY OWNERSHIP Provide Corporate Officer (The Tulalip Tribes) form is 1 page long and contains:

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  • 4 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

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WHOLESALE FIREWORKS APPLICATION
PLEASE USE DARK INK. IF ANY ITEM IS NOT APPLICABLE OR NO INFORMATION IS AVAILABLE, INDICATE BY MARKING
WITH “N/A” OR STRIKE THROUGH. INCOMPLETE AND/OR ILLEGIBLE APPLICATIONS WILL BE RETURNED TO APPLICANT.
The Tulalip Tribes of Washington
Community Development Department
TAX & LICENSING DIVISION
6406 Marine DR NW
Tulalip
, WA 98271
Telephone: (360) 716-4204
PAYMENT SUMMARY
FEE
Enclose payment for total amount due, including application and applicable penalty fees. Accepted
forms of payment are cash, check, and money order made payable to The Tulalip Tribes / TLD.
License fees are not pro-rated and are nonrefundable.
APPLICATION FEE
$ 100.00
TOTAL AMOUNT DUE
$
OWNERSHIP – Provide Corporate Officer Information on separate sheet
Please choose one:
INDIVIDUAL
PARTNERSHIP
CORPORATION
OTHER
Licensee/Partner Name (Last, First, Middle)
D.O.B.
/ /
WA ID #
Licensee/Partner Name (Last, First, Middle)
D.O.B.
/ /
WA ID #
Firm /Business Address (Street or Route, PO BOX)
Federal ID #
UBI #
City, State, Zip
Mailing Address (Street or Route, PO BOX)
City, State, Zip
DESIGNATED AGENT AND ONSITE ASSISTANTS
Designated WA State Agent
D.O.B.
/ /
WA ID #
Business Telephone #
( ) -
Complete Mailing Address
Email Address
Assistant Name (Last, First, Middle)
D.O.B.
/ /
WA ID #
Attach
separate list
if necessary
– include
photocopies
of IDs with
application.
Assistant Name (Last, First, Middle)
D.O.B.
/ /
WA ID #
Assistant Name (Last, First, Middle)
D.O.B.
/ /
WA ID #
Assistant Name (Last, First, Middle)
D.O.B.
/ /
WA ID #
APPLICANT BACKGROUND - Attach separate sheets for explanations if necessary
Has any member of the company been convicted for tribal, state, or federal fireworks violations within the past 5 years? If yes, explain:
YES
NO
Has any member been cited or is presently appealing any civil or criminal fines or penalty? If yes, explain:
YES
NO
Does the company hold current all required state and federal licenses? If yes, please provide a copies with application
YES
NO
Has company ever had a fire, accident, and/ or caused damage to another’s property as a result of fireworks activity? If yes, explain:
YES
NO
SIGNATURE REQUIRED
Your signature attests to the accuracy of the information provided and that your business will comply with all applicable Tribal and Local Laws
BY SIGNING BELOW, I UNDERSTAND AND AGREE TO THE FOLLOWING:
I, THE UNDERSIGNED DECLARE UNDER PENALTY OF PURJURY AND/OR REVOCATION OF ANY LICENSE GRANTED, THAT I HAVE EXAMINED THIS APPLICATION
AND THE INFORMATION CONTAINED HEREIN AND/OR ATTACHED, AND THE INFORMATION PROVIDED BY ME AND MY PARTNER IS TRUE AND CORRECT. I
SWEAR OR AFFIRM TO COMPLY WITH ALL TRIBAL LAWS AND CONSENT TO THE JURISDICTION OF THE TRIBAL COURT OF THE TULALIP TRIBES AND SERVICE
OF PROCESS IN MATTERS ARISING FROM THE CONDUCT OF BUSINESS.
Licensee/Partner Signature
Date
Licensee/Partner Signature
Date
LICENSE NUMBER
BC 2014
LICENSEE NAME(S)
/
ID(s)
Cert of Insur
Inventory List
Other
A
B
E
D
C
Wholesale Fireworks App Revised May 2013 Page 1 of 1
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BC 2014 PAYMENT SUMMARY OWNERSHIP Provide Corporate Officer (The Tulalip Tribes)

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Completed 20 July 2020

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