Form 2643a - Missouri Tax Registration Application

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Department Use Only

Missouri Department of Revenue

Form

(MM/DD/YY)

Missouri Tax Registration Application

2643A

Missouri Tax I.D.

Federal Employer

Number

I.D. Number

(Optional)

Answer all questions completely. Incomplete and unsigned applications will delay

processing..

3. Select all tax types for which you are applying:

New MO Registration

Sales from a Missouri business location

Missouri Employer Withholding Tax

Purchase of Existing Business

Retail Sales*

Regular Withholding

Reinstating Old Business

Temporary Retail Sales* (Less than 191 days)

Domestic or Household Employee

Converted (must have converted

Retail Liquor or Alcohol Sales*

Transient Employer*

through the Missouri Secretary of

State’s office)

Sales or Purchases from an out-of-state location

Corporate Tax

Court Appointed Receiver

Vendor’s Use*

Corporate Income

Other:

Consumer’s Use (Missouri purchases

Corporate Franchise

where tax is not collected.)

*Bond Required

4. Business Name (DBA name: attach list if necessary for additional locations)

Street, Highway (Do not use P.O. Box Number or Rural Route Number)

City

County

State

Zip Code

Business Telephone Number

(

)

___ ___ ___

___ ___ ___ ___

5. Will sales be made at various temporary locations in Missouri?

Yes—Attach a list of all known locations. If no Missouri location is given during initial registration, a general location will be used.

6. Is this business located inside the city limits of any city or municipality in Missouri? To verify go to

https://dors.mo.gov/tax/strgis/index.jsp

______________________________________________________________________ ___

Yes — Specify the city:

7. Is this business located inside a district(s)? For example, ambulance, fire, tourism, community or transportation development.

________________________________________________________________

Yes — Specify the district name(s):

8. Describe the business activity, stating the major products sold and services provided. ____________________________________________

_________ _______________________________________________________________________________________________________

_____%

______________

Retail

Wholesale

Service

Manufacturer

Contractor

Other _

9. Do you make retail sales of the following items? Select all that apply.

Alcoholic Beverages

Alternative Nicotine

Cigarettes or Other Tobacco Products

Domestic Utilities

E-Cigarettes or Vapor Products

Food Subject to Reduced State Food Tax Rate

Items Qualifying for Show Me Green Sales Tax Holiday

Items Qualifying for Back-To-School Sales Tax Holiday

Lead-Acid Batteries

New Tires

Post-Secondary Educational Textbooks

Telecommunication Services

Qualifying Utilities or Items Used or Consumed in Manufacturing or Mining, Research and Development, or Processing Recovered Materials.

10. Do you make retail sales of aviation jet fuel to Missouri customers? ...........................................................................................

Yes

If yes, are your sales made at:

A Missouri airport?

A location outside Missouri and the fuel is transported into Missouri?

If yes, is the airport located in Missouri and identified on the National Plan of Integrated Airport Systems (NPIAS)? ................

Yes

If yes, provide a list of applicable locations. _____________________________________________________________________________

11. Do you use, store, or consume aviation jet fuel in Missouri where the seller does not collect tax? .............................................

Yes

If yes, is the fuel stored, used, or consumed in an airport that is identified on the NPIAS? .........................................................

Yes

If yes, provide a list of applicable locations: _____________________________________________________________________________

12. Do you lease or rent motor vehicles that were purchased sales tax exempt, to Missouri customers? ........................................

Yes

If you are an out-of-state company, will you lease motor vehicles to a Missouri resident where the lease is entered into

outside Missouri and the motor vehicle is delivered outside Missouri? ........................................................................................

Yes

*14606010001*

14606010001