Member Application Form Please complete this application on a

Member Application Form
Please complete this application on a form you have downloaded
and saved to your computer.
Once submitted and approved, you will be eligible to have your
product included on the Genuine West Virginia Products Program Web site.
Once an application is received, it will be evaluated to determine if your company and
product complies with the program criteria.
Business Name:
Contact Name:
Address:
City:
County:
Zip:
Business Phone:
E-mail Address:
Web Site Address:
General description of the product:
Type of business (check one):
Profit
Number of years in business:
Number of years producing the product:
Type of Distribution:
Retail
Wholesale
Direct Sales
Catalog
Distributer
Other
(please describe)
Non-profit
Approximate annual gross sales:
Number of full- or part-time employees:
If sold at retail, please list primary retail locations:
Approximate percent of the product raw material that is made in West Virginia:
Primary means of marketing or advertising:
Warranties or guarantees offered:
“I hereby certify that the information contained in this application is true to the best of my
knowledge.”
Name:
Signature: __________________________________________________________
Date:
All businesses applying for the Genuine West Virginia Products Program must be
current and in good standing with a valid state business license; all applicable state
business taxes; unemployment compensation and workers compensation.
A verification process for each of the above will be completed by the Department of
Commerce prior to the inclusion of your business into the Genuine West Virginia
Products Program. In order to assist the process, we ask you to please answer the
following questions and to provide the material requested.
1. Please indicate below which business classification applies to your company:
____Corporation (filed with the Secretary of State)
____Limited Liability Company (filed with the Secretary of State)
____Limited Partnership (filed with the Secretary of State)
____Limited Liability Partnership (filed with the Secretary of State)
____Voluntary Association (filed with the Secretary of State)
____Sole Proprietorship (filed with the WV State Tax Department)
____General Partnership (filed with the WV State Tax Department)
____Other (please specify)
2. Included with this application is an Authorization to Release Information form,
provided by the West Virginia State Tax Department
The WV State Tax Department requires this form as a result of the West Virginia
Tax Procedure and Administration Act, which prevents the Tax Department from
disclosing any information without having a waiver of confidentiality.
Please complete a notarized copy of this form.
3. For verification of unemployment compensation, a Certificate of Good Standing
from WorkForce West Virginia is required for acceptance into the Genuine West
Virginia Products Program.
Please contact Workforce West Virginia to request a Certificate of Good
Standing. You may call 304-558-2451 or email [email protected]
An unemployment compensation employer account number and the name of the
agency seeking the certificate (WV Department of Commerce) will be requested.
Please mail (1) the completed Genuine West Virginia application form, (2) a notarized
copy of the State Tax Department’s Authorization to Release Information form, (3) the
unemployment compensation Certificate of Good Standing, and one product photo to:
Genuine West Virginia Products Program
WV Dept. of Commerce, Communications
90 MacCorkle Ave. SW
South Charleston, WV 25303
For any questions regarding the Genuine West Virginia Products Program, please call
304-957-9320.
The Genuine West Virginia Products Program reserves the right to exclude any product
from the program, including, but not limited to, any product which is suggestive of
religious, political, racial or sexual content.
The Genuine West Virginia Products Program requires all product producers to abide by
the policies set forth by the West Virginia Department of Commerce. TO:
The West Virginia State Tax Commissioner
WV-ARI-001
(Rev.2/05)
AUTHORIZATION TO RELEASE INFORMATION
Name of Taxpayer
Date:
Address:
City:
Daytime Telephone:
State:
Zip Code:
Fax:
Company Contact to whom information may be released:
E-mail address of Company Contact:
West Virginia Identification, SSN, FEIN or Other:
The above named taxpayer does hereby waive the confidentiality provisions of West Virginia Code §11-10-5d
and/or §11-1A-23 to the following extent:
1.
Persons to whom information may be released:
Name: Mel Hobbs, Department of Commerce, Communications
Address: 90 MacCorkle Ave. SW
Daytime Telephone
City:
State:
2.
South Charleston
Capacity: Genuine West Virginia Products
Program
(304) 957-9320
West Virginia
Zip Code:
25303
Effective period of this waiver:
____
authorization terminates
____________________________________________________________
month
day
year
____
until my liability for the delinquent tax or taxes checked in paragraph 3, below, is satisfied.
X
other (explain) For the duration of the period the company is a member within the Genuine West Virginia
Products Program
3. Taxes and/or credits to which this waiver applies:
W.Va. Code
___ Beer Barrel Tax
11-16
___ Business & Occupation Tax
11-13
___ Business Franchise Tax
11-23
___ Charitable Raffle Boards & Games 47-23
___ Consumers Sales & Service Tax
11-15
___ Corporate License Tax
11-12C
___ Corporate Net Income Tax
11-24
___ Economic Opportunity Tax Credit 11-13Q
___ Employers Withholding Tax
11-10
___ Estate Tax
11-11
___ Gasoline & Special Fuel Excise Tax 11-14
___ HealthCare Provider Taxes
11-27
___ IFTA
11-14B
___ Manufacturing Investment Tax
Credit
11-13S
____
____
____
____
____
____
____
____
____
____
____
____
_xxx
____
____
Minimum Severance Tax on Coal
Motor Carrier Road Tax
Personal Income Tax
Property Taxes
Severance Tax
Solid Waste Fee
Soft Drink Tax
Strategic Research & Development
Tax Credit
Telecommunications Tax
Tobacco Products Excise Tax
Use Tax
Wine Liter Tax
All of the above applicable taxes
to the taxpayer
Other Taxes (As Listed Below)
W.Va. Code
11-12B
11-14A
11-21
11-13A
20-5F
11-19
11-13R
11-13B
11-17
11-15A
60-8
4. Information to be released (Describe specifically).
_Any information pertinent to receive a tax clearance for certificate with the WV State Tax Department.________
____Status of all taxes.______________________________________________________________________________
5. Reason(s) why information is to be released:
To be eligible for inclusion into the WV Dept. of Commerce Genuine West Virginia Products Program
This waiver will be effective only to the extent explained above and any other release of information is not
permitted without additional authorization. Additionally, information will be released only to the extent the Tax
Commissioner believes disclosure is necessary to comply with this Authorization to disclose information, and will
not be disclosed to the extent the Tax Commissioner determines that disclosure would seriously impair
administration of this State’s Tax laws.
This authorization must be signed by the taxpayer, or taxpayer’s authorized representative, and the signature of
the person signing the authorization must be notarized.
Authorization is for:
. release of a jointly filed personal income tax return, the authorization must be signed by either the husband or
the wife.
. release of a return filed by a business that is a sole proprietorship, the authorization must be signed by the owner
of the business or by an employee of the business , or other person, who is authorized to sign the authorization.
. a corporation, the authorization must be signed by its president, vice president, treasurer, assistant treasurer,
chief accounting officer or other person duly authorized to sign the authorization.
. release of a return filed by a partnership, as defined for federal income tax purposes, the authorization must be
signed by the managing partner, or tax matters partner, or any other partner or employee of the partnership
authorized to sign the authorization.
. release of a return filed by a limited liability company, the authorization must be signed by the managing
member, tax matters member, or any other member or employee of the limited liability company authorized to
sign the authorization.
. a return filed by an estate or trust, the authorization must be signed by the executor or executrix of the estate, or
the trustee of the trust.
. for information other than a tax return, the authorization must be signed by a person who could authorize
release of taxpayer’s tax return.
PLEASE NOTE – THE SIGNATURE BELOW MUST BE AN OFFICER OR MEMBER OF THE
BUSINESS ENTITY, NO OTHER SIGNATURE WILL BE ACCEPTED.
______________________________________________________
Print Name
______________________________________________________
Signature
______________________________________________________
Capacity
State of West Virginia
County of __________________, to wit,
______________________________________________________
Date
This day appeared before me, the undersigned notary public, _____________________________________ who acknowledge
under oath the signature above.
(Print Taxpayers’ Name)
_______________________________________________________
Notary Public
_______________________________________________________
Date
My commission expires: ____________________________________________________________________________________.