Scrap Metal Dealer Registration Form Filing type (check one) Original filing Amended filing Please note that there is NO FILING FEErequired to register as a scrap metal dealer. Business Information Business name County Hours of operation Address, City, State, Zip Organizationlicensed through (check one) West VirginiaSecretary of State West Virginia State Tax Department* (see note) *If your business is licensed through the WV State Tax Department, please attach a copy of your business registration certificate. You may contact the State Tax Department at 304-558-3333 or 1-800-982-8297. Primary phone # Secondary phone # Fax number Website address Officers Officer type(check one) Full nameand title Phone number Email address Owner Principal Owner Principal Owner Principal Owner Principal Physical Location#1 Address, City, State, Zip County Hours of operation Primary phone # Secondary phone # Fax number Physical Location#2 Address, City, State, Zip County Hours of operation Primary phone # Secondary phone # Fax number By signing your name below and submitting this form you are certifying as follows: 223I certify the information provided is true. I further certify that I am duly authorized to file this document on behalf of this organization as required by West Virginia Code.224 Print name and title Signature* (see instructions) Date DO NOT COMPLETE THIS SECTION!This section for use by WV SOS Staff ONLY Date processed SOS Org ID Gentax ID SCRAP METAL DEALER REGISTRATIONForm SMD-1 Rev. 11/2017West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov INSTRUCTIONS FOR FILING SCRAP METAL DEALER REGISTRATION FORM BEFORE you fill out the application: The business name you select will be approved only if it is available 226 that is, if the name is not the same as and is distinguishable from any other name which has been reserved or filed. If you prepare business registration papers without applying for and receiving a name reservation, you do so at your own risk. A telephone check on availability of a name is NOT a guarantee.You may apply for a name reservation in writing, accompanied by a $15 fee payable to the Secretary of State, mailed to the address on the top of the application. Once approved, the name will be held for 120 days. ******There is NO FILING FEE to file the Scrap Metal Dealer Registration****** FILLING OUT THE APPLICATION: NOTE:The applicant agrees to register a scrap metal dealer in accordance with24761-3-49-(b)(4) of the revised West Virginia State Business Code which states the following: (4) Register as a scrap metal dealer with the Secretary of State, who is hereby directed to maintain a list of scrap metal dealers and make it publically available. The list shall include the dealer222s business address, hours of operation, physical address, phone number, facsimile number, if any, and the name of the owners and principal officers of the business. Filing Type - Check the ONE which applies to your filing type: 225Original filing 226 your initial business registration with the West Virginia Secretary of State.225Amended filing 226 any amendments made to the registered business after the initial registrationwith the West Virginia Secretary of State.Business Information Business Name 226 enter the business name exactly as it is registered with the West Virginia Office of the Secretary of State. County 226 enter the county name in which the business is located in West Virginia. If located outside the state of West Virginia (i.e., a foreign business formed outside the State of West Virginia) enter the number zero 2230224. Hours of Operation 226 enter the regular hours of operation the business intends to transact regular business activities. Address, City, State, Zip 226 enter the current number and street address, city, state, and zip code of the principal office location of the business. Type of organization - Check the ONE which applies to your filing type: 225Licensed through West Virginia Secretary of State225Licensed through West Virginia State Tax Department* (see note)*If your business is licensed through the WV State Tax Department, please attach a copy ofyour business registration certificate. You may contact the State Tax Department at 304-558-8683 or 1-800-982-8297. Primary phone number 226 enter the primary contact phone number for the business (ex: 555-555-5555). Secondary phone number 226 enter the secondary contact phone number for the business, if any (ex: 555-555-5555). Fax number 226 enter the fax number for the business, if any (ex: 555-555-5555). Website address 226 enter the current business website address of the business, if any. Officers Officer type 226 check ONE type (Owner OR Principal) per each individual officer listed. You may list up to four [4] officers. Attach additional pages if necessary to list additional officers. Physical Location #1 Address, City, State, Zip 226 enter the current number and street address, city, state, and zip code of the physical office location of the primary (#1) physical business location. County 226 enter the county name where the primary (#1) physical business is located in West Virginia. If located outside the state of West Virginia (i.e., a foreign business formed outside the State of West Virginia) enter the number zero 2230224. Hours of Operation 226 enter the regular hours of operation the primary (#1) physical business location intends to transact regular business activities. Primary phone number 226 enter the primary contact phone number for the primary (#1) physical business location (ex: 555-555-5555). Secondary phone number 226 enter the secondary contact phone number for the primary (#1) physical business location, if any (ex: 555-555-5555). Fax number 226 enter the fax number for the primary (#1) physical business location, if any (ex: 555-555-5555). Physical Location #2 Address, City, State, Zip 226 enter the current number and street address, city, state, and zip code of the physical office location of the secondary (#2) physical business location. County 226 enter the county name where the secondary (#2) physical business is located in West Virginia. If located outside the state of West Virginia (i.e., a foreign business formed outside the State of West Virginia) enter the number zero 2230224. Hours of Operation 226 enter the regular hours of operation the secondary (#2) physical business location intends to transact regular business activities. Primary phone number 226 enter the contact phone number for the secondary (#2) physical business location (ex: 555-555-5555). Secondary phone number 226 enter the secondary contact phone number for the secondary (#2) physical business location, if any (ex: 555-555-5555). Fax number 226 enter the fax number for the secondary (#2) physical business location, if any (ex: 555-555-5555). Note :By signing your name below and submitting this form you are certifying as follows: 223I certify the information provided is true. I further certify that I am duly authorized to file this document on behalf of this organization as required by West Virginia Code.224 Signature and Date Print name and title 226 print clearly the first and last name AND title of the applicant having signature authority to transact business on behalf of the organization. Signature* (see note below)226 the applicant having signature authority to transact business on behalf of the organization must sign in the space provided for the registration to be valid and processed in a timely manner. *Important Legal Notice Regarding Signature :Corporations/Voluntary Associations/Business Trusts/Unincorporated Nonprofit Associations/Limited Partnerships - Per West Virginia Code24731D-1-129 . Penalty for signing false document. Any person who signs a document he or she knows is false in any material respect and knows that the document is to be delivered to the Secretary of State for filing is guilty of a misdemeanor and, upon conviction thereof, shall be fined not more than one thousand dollars or confined in the county or regional jail not more than one year, or both. Limited Liability Companies/Limited