Form 2643a - Missouri Tax Registration Application - 2013 Page 2
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4Reset Section 22 through 26
If you are NOT an out-of-state business, skip to Line 27.
IF YOU ARE AN OUT-OF-STATE BUSINESS DOING BUSINESS IN MISSOURI, PLEASE ANSWER THE FOLLOWING QUESTIONS.
22. Do you have a location or job site in Missouri? If yes, attach a list of your locations including address, city, state,
and zip code. Indicate if the location is inside or outside the city limits. ...........................................................................................
Yes
No
23. Are orders taken from your Missouri customers by telephone, non-resident salesmen, etc.? If resident salesmen, attach a list
of cities in which they live and indicate if they are inside or outside the city limits. ...........................................................................
Yes
No
24. Do your representatives who reside in Missouri:
A. Approve customer orders? ............................................................................................................................................................
Yes
No
B. Make on the spot sales? ...............................................................................................................................................................
Yes
No
C. Maintain an inventory? ..................................................................................................................................................................
Yes
No
D. Deliver merchandise to the customer? .........................................................................................................................................
Yes
No
25. Do you have non-resident representatives, agents or temporary employees coming into Missouri on a regular or systematic basis?
Yes
No
If yes, define the activities performed while in Missouri. _____________________________________________________________________________
_________________________________________________________________________________________________________________________
26. Do you have real or tangible personal property in Missouri? .............................................................................................................
Yes
No
If yes, please describe: ______________________________________________________________________________________________________
OWNERSHIP TYPE
27. Ownership Type
Sole Proprietor
Partnership
Government
Trust
All ownership types listed below, unless specifically exempted, are required to be registered with the Secretary of State’s Office,
or call 1-866-223-6535. Your application will not be complete without providing the charter number issued to you
.
by the Missouri Secretary of State’s Office
Limited Partnership — LP Number ___________________________________________
Other __________________________________
Limited Liability Partnership — LLP Number ____________________________________
__________________________________________
Limited Liability Company — LLC Number ______________________________________
Taxed as a
Disregarded Entity
Partnership
Corporation
Missouri Corporation — Missouri Charter No. ___________________________________
Date Incorporated ________________________
Non-Missouri Corporation — Certificate of Authority No. ___________________________
State of Incorporation and Date Registered in
Missouri _______________________________
Not Required to register with Missouri Secretary of State
_______________________________________
OWNER NAME AND ADDRESS
Reset Section 28
28. Owner Name (Enter Corporation or LLC Name, if applicable)
If the owner is a sole owner or a partnership, you must provide:
It is not necessary to type hyphens or dashes.
Social Security Number
Date of Birth(MM/DD/YYYY)
Telephone Number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ /___ ___ /___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Address
E-Mail Address
City
State
Zip Code
County
__ __ __ __ __
Reset Section 29
PREVIOUS OWNER INFORMATION (MUST BE COMPLETED)
29. Is there a previous owner/operator for the business?
Yes*
No *If yes, the following section must be completed.
Check any of the following that you purchased from the previous owner:
Purchase Price
Inventory
Fixtures
Equipment
Real Estate
Other _____________________________
Name of Previous Owner/Operator
Missouri Tax ID No.
___ ___ ___ ___ ___ ___ ___ ___
Physical Location of Previous Business
Address of Previous Business
DOR-2643A (03-2013)
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