Combined Employer'S Registration Form
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COMBINED EMPLOYER'S REGISTRATION
FOR AGENCY USE ONLY
BIN
Date received
• We cannot issue a Business Identifi cation Number (BIN)
if your registration is incomplete.
E/R code
County
NAICS
• Be sure to read the instructions on the back.
• You must fi ll in the date employees were fi rst paid.
• Please type or print.
Business name
Type of Ownership (check one):
Corporation
Limited Liability Part.
Pension and Annuity
Assumed business name
Government
—Federal
Non-profi t 501(c)(3)
Political Campaign
(attach federal exemption)
Government
Single Member LLC
—Local
Federal EIN
Business telephone number
Government
Other Nonprofi t
Sub-chapter S Corp
—State
Individual
Partnership
—General
Other
Ext.
(describe below):
Person at business authorized to discuss your payroll account with us
_________________
Limited Liability Co.
Partnership
—Limited
Check if Construction Contractors Board (CCB) only
Ext.
Business mailing address
Nature and principal products of your business (i.e., retail—men's clothing;
services—janitorial; etc.). Be specifi c.
City
State
ZIP Code
Check if any employees are:
E-mail address
Fax number
Agricultural
Working on fi shing vessels
Domestic (in-home workers)
Does any domestic worker request withholding?
Yes
No
Physical location of business in Oregon—street address
Type of return to be fi led (see instructions)
OQ (Oregon Quarterly)
WA (Federal 943 fi lers only)
OA (Domestic)
City
State
ZIP Code
Approximate number of employees
WITHHOLDING
TAX
Do you have any other locations in Oregon? (see instructions for listing all locations)
Date employees were/will fi rst be paid for work in Oregon
Must be
Yes
No
➛
Month _________ Day ________ Year ________
completed
Off site payroll service, accountant, or bookkeeper (attach Power of Attorney)
Check if any employees work in these areas (see instructions)
TriMet (Portland and surrounding metropolitan areas)
TRANSIT
LTD (Eugene and Springfi eld areas)
Contact person at the off site payroll service, accountant, or bookkeeper
TAX
Date employees fi rst paid for services performed within district(s)
Phone
Mailing address for off site payroll service (send:
TriMet __________________ LTD __________________
forms
billings to this address?)
C/O
In what calendar quarter did/will your payroll fi rst exceed $225?
City
State
ZIP Code
Exceptions: $20,000 Agricultural
$1,000 Domestic (see instructions)
UNEMPLOYMENT
Quarter ___________ Year ___________
TAX
Bank reference/branch address
Date fi rst Oregon employee was hired/will be hired
Month _________ Day ________ Year ________
Date of acquisition
Business ID No. of acquired business
Did you acquire all or part of the Oregon business operations of an ongoing business?
Yes
No
Was it a:
Partial acquisition
Total acquisition
List acquired business name, previous owner, and telephone number
IDENTIFICATION OF OWNERS, PARTNERS, CORPORATE OFFICERS, ETC.
(List additional owners on a separate sheet and attach to this form)
Social Security number
Federal EIN
Telephone number
Social Security number
Federal EIN
Telephone number
Name
Name
Home address
Home address
City
State
ZIP Code
City
State
ZIP Code
Responsible for:
Responsible for:
Filing tax returns
Paying taxes
Hiring/fi ring
Filing tax returns
Paying taxes
Hiring/fi ring
Determining which creditors to pay fi rst
Determining which creditors to pay fi rst
AUTHORIZATION
I certify the above statements to be true and correct. I authorize the Employment Department and the Department of Revenue to verify any of the above
information with regard to this business. I will notify each agency if there is a change or cancellation of the above authorized representative.
Signature
Date
Signature
Date
X
X
150-211-055 (Rev. 8-04) Web
503-947-1528
Fax to:
— or—
Mail to
:
OREGON DEPARTMENT OF REVENUE
PO BOX 14800
SALEM OR 97309-0920
Retain a copy for your records.
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Parent category: Financial