Form 150-603-002 Registration For Oregon Emergency Communications Tax
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1Clear Form
FOR REVENUE USE ONLY
REGISTRATION FOR OREGON
Date Received
EMERGENCY COMMUNICATIONS TAX
Business Identification Number (BIN)
Business Name
Federal Employer Identification Number (FEIN)
Physical Address of Business
City
State
ZIP Code
County
Mailing Address
City
State
ZIP Code
Business Telephone Number
(if different from above)
(
)
Location of Business Records
City
State
ZIP Code
Fax Number
(if different from above)
(
)
Type of Organization
Sole Proprietor
Partnership
Corporation
LLC
Other ___________________________
Names of Owner, Partner, or Corporation Officers. Please print clearly (use additional sheets if neccessary):
Name
Street Address
City, State, ZIP Code
Social Security Number
Contact Person
Telephone Number
(
)
Nature of Business
Telecommunications Utility
Cellular Telephone Company
Other _________________________
(Describe)
At registration, I elect to pay the tax based on the following method (you cannot change this method unless you first obtain
permission from the Oregon Department of Revenue):
Amount of tax collected during the quarter. - Method 1
Net amount of tax billed during the quarter (gross amount billed less adjustments). - Method 2
This information will be used primarily by the Oregon Department of Revenue for identification and compliance purposes
in the administration of the Emergency Communications Tax Program.
I declare under the penalties for false swearing [ORS 305.990(4)] that I have examined this document and to the best of
my knowledge it is true, correct, and complete.
Signature
Title
Date
X
150-603-002 (Rev. 2-07) Web
Mail to: EMERGENCY COMMUNICATIONS TAX
OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910
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