CRF-003 REV. 5/05 GEORGIA DEPARTMENT OF REVENUE REGISTRATION & LICENSING UNIT P. O. BOX 49512 ATLANTA, GA 30359-1512 404-417-4490 TSD-sales-tax-lic@dor.ga.gov ADDITIONAL ADDRESS FORM (Complete Only If Necessary) (PLEASE PRINT OR TYPE) FOR OFFICE USE ONLY LEGAL BUSINESS NAME: ADDITIONAL MAILING ADDRESS (Please identify tax type(s) to be mailed to the address below.) Sales & Use Withholding Tobacco Amusement ADDRESSEE (C/O) (If different from or in additi A lc ohol Motor Fuel Distributor on to the Legal Business Name) N U MB E R A N D S T R E E T , P . O . B O X , R F D N O . CITY STATE ZIP E-MAIL ADDRESS F A X N U MB E R ( ) COUNTRY PHONE NUMBER ( ) COUNTY ADDITIONAL MAILING ADDRESS (Please identify tax type(s) to be mailed to the address below.) Sales & Use Withholding Tobacco Amusement ADDRESSEE (C/O) (If different from or in additi A lc ohol Motor Fuel Distributor on to the Legal Business Name) N U MB E R A N D S T R E E T , P . O . B O X , R F D N O . C IT Y S T AT E Z IP E-MAIL ADDRESS F A X N U MB E R ( ) C O UNT R Y P H O N E N U MB E R ( ) C O UNT Y ADDITIONAL MAILING ADDRESS (Please identify tax type(s) to be mailed to the address below.) Sales & Use Withholding A lc ohol Tobacco Amusement Motor Fuel Distributor ADDRESSEE (C/O) (If different from or in addition to the Legal Business Name) NUMBER AND STREET, P. O. BOX, RFD NO. CITY STATE ZIP COUNTY COUNTRY PHONE NUMBER ( ) ADDITIONAL MAILING ADDRESS (Please identify tax type(s) to be mailed to the address below.) Sales & Use Withholding A lc ohol Tobacco Amusement Motor Fuel Distributor ADDRESSEE (C/O) (If different from or in additi on to the Legal Business Name) N U MB E R A N D S T R E E T , P . O . B O X , R F D N O . CITY STATE ZIP E-MAIL ADDRESS F A X N U MB E R ( ) COUNTRY PHONE NUMBER COUNTY ( ) SIGNATURE SECTION I HAVE EXAMINED THIS FORM, AND TO THE BEST OF MY KNOWLEDGE IT IS TRUE AND CORRECT. Signature (MUST BE SIGNED BY OWNER, PARTNER, OR CORPORATE O Title Date FFICER AS LISTED IN THE RELATIONSHIP SECTION ABOVE.) American LegalNet, Inc. www.FormsWorkflow.com