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Form 62a370a - Application For Certificate Of Registration To Purchase Certificates Of Delinquency

Form #62A370A

11/09

Date Stamp

Office Use Only

KENTUCKY DEPARTMENT OF REVENUE

APPLICATION FOR

CERTIFICATE OF REGISTRATION TO

PURCHASE CERTIFICATES OF DELINQUENCY

A decision on a completed application will be made within ten (10) days of its receipt. To ensure that your application is complete please

review each question and use the check box

when all items or questions are satisfied. Failure to file a completed application may result

in the denial of your application. Your responses to the questions on this application are continuing in nature. You must promptly notify the

Commissioner of any circumstance that would cause your answers to change. Please note that “You” refers to any person included as part

of this application, including any owners, officers, directors or business entity. Please type or print clearly in dark ink.

Section A: All applicants must complete this section

A1.

Applicant is a(n):

Corporation

Unincorporated Association

Limited Liability Company

Partnership

Limited Liability Partnership

Individual/Sole Proprietorship

Other:

A2.

Name under which applicant will conduct business:

A3.

The name and street address of applicant’s principal place of business:

A4.

Tax ID or social security # of applicant:

Telephone #:

Fax #:

A5.

Name, telephone number and email address of principal contact for registration and compliance matters.

A6.

Name, telephone number and email address of principal contact for consumer complaints.

A7.

Name, telephone number and email address of operation/general manager.

A8.

Address where records pertaining to Kentucky transactions will be maintained.

A9.

Have you ever been issued registration by this office? If yes, list the date(s) held.

Yes

A10. Have you ever been denied a registration, or had a registration suspended or revoked, by this State Yes

or any other state? If yes, please provide a detailed explanation:

Form 62a370a - Application For Certificate Of Registration To Purchase Certificates Of Delinquency

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