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hio
ST 1D
Department of
Rev. 12/09
Taxation
Application for
P .O. Box 182215
07100100
Delivery Vendor's License
Columbus, OH 43218-2215
(888) 405-4089
Vendor's license no.
(For department use only)
Federal employer identifi cation no.
Ohio corporate charter no. / certifi cate no.
Social Security no. / ITIN
1. Check type of ownership: (10) Sole owner
(20) Partnership
(30) Corporation
(150) Nonprofi t
(50) LLC
(70) LLP
(80) LTD
Other (please specify)
2. When did you or will you start making taxable sales? (MM/DD/YY)
3. Provide NAICS code
(For the most current listings, search NAICS on our Web site at tax.ohio.gov.)
Briefl y describe your business and method of operation
4. Legal name
(Corporation, sole owner, partnership, etc.)
5. Trade name or DBA
6. Primary address
Address of corporation, sole owner, partnership, etc.
City
State
ZIP code
Business phone no.
Fax no.
Secondary phone no.
7. Mailing address
(If different from above)
City
State
ZIP code
8. How much sales tax do you expect to collect each month? Less than $200
$200 or greater
9. If you operate as a corporation or partnership, list appropriate names, addresses and identifi cation numbers below.
Title
Name
Street
City
State
ZIP code
SSN / ITIN / FEIN
Title
Name
Street
City
State
ZIP code
SSN / ITIN / FEIN
Title
Name
Street
City
State
ZIP code
SSN / ITIN / FEIN
10. Name, phone number, fax number and e-mail address of individual the department should contact regarding this account
Name
Phone no.
Fax no.
E-mail address
Date
Signature of applicant
Fee for this license – $25 (made payable to Ohio Treasurer of State). Send the original application and $25 fee to
the address above.