State of Washington Business Licensing Service PO BOX 9034 OLYMPIA, WA 98507-9034 Information provided may be subject to disclosure under the public disclosure law (RCW 42.56) UBI NUMBER OWNER NAME (Please print clearly) FOR VALIDATION -- OFFICE USE ONLY Location Addendum Complete one Location Addendum for each business location not listed on the Business License Application. This form must accompany a Business License Application. Business License Application To The 03N-400-925-0003 1. LIST REGISTRATIONS, LICENSES, TRADE NAMES AND ANY REQUIRED FEES BELOW Use the"License Fee Sheet" for the information needed to complete this list. REGISTRATION OR LICENSE TYPE $ $ $ $ FEE Enclose a check for the total amount due, including the Application Fee, which MUST be submitted with this form Make check payable to the Department of Revenue. $ APPLICATION FEE $ TOTAL AMOUNT DUE 19.00 A BUSINESS INFORMATION (Complete for actual location where business will be conducted.) Date business first will be (was) conducted, under this owner, at this WA location: Mo Day Yr Firm/Trade Name Business Mailing Address (Street or Route, P.O. Box, City, State, Zip) Business Location (Street or Route, City, State, Zip -- Physical location only) Business Telephone Number ( ) FAX Number County Is this location within city limits? YES NO If yes, which city? Describe in detail the principal products or services you provide in Washington: (product manufactured or sold, type of construction, etc.) B COMPLETE IF THE BUSINESS YOU ARE REGISTERING HAD A PRIOR OWNER If yes, check one box ALL Mo Day Did you buy, lease or acquire all or part of an existing business? YES NO Previous Business Name PART Previous Owner's Name and Address Yr Previous Owner's Telephone No. ( ) Still in Business? YES NO Date Bought/Leased/Acquired C COMPLETE IF YOU EMPLOY OR PLAN TO EMPLOY ONE OR MORE PERSONS IN WASHINGTON Number of persons you employ or plan to employ at this location (Do not include owners) Of these, how many are or will be minors (under age 18)? Are any of these minors under age 16? Are the minors working in an agricultural business? YES NO YES NO Date of first employment of planned employment at this location List the specific duties performed by minors at this location Describe in detail the activities of your employees D SIGNATURE OF SOLE PROPRIETOR OR SPOUSE, PARTNER, OR CORPORATE OFFICER I, the undersigned, declare under the penalties of perjury and/or the revocation of any license granted, that I am the applicant or authorized representative of the firm making this application and that the answers contained, including any accompanying information have been examined by me and that the matters and things set forth are true, correct and complete. Signature required Title Date To receive this document in an alternate format, please call 1-800-647-7706. Teletype (TTY) users may use the Washington Relay Service by calling 711. BLS-700-029 (08/08/13) American LegalNet, Inc. www.FormsWorkFlow.com X