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: ____________________________________________________________________________________.
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