Form Tc-69 - Business And Tax Registration October 2001 Page 2
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41e. Owner’s Name - PRINT
Name of individual or entity that owns the business
Daytime Phone Number
Office Use Only (USTC)
Owner’s Street Address
City
County
State
Zip Code
1f. DBA (Doing Business As)
Business or trade name
Business Phone Number
Business Location – physical street address of business (P.O. Box not acceptable)
City/County Code
City
County
State
Zip Code
1g. Business Mailing Address
Write “same” if same as business location (1f).
SIC Code
City
County
State
Zip Code
1h. Business Description
Describe in detail the specific nature of your business.
USTC SIC
If you are a restaurant, check the box that best describes your business:
Fast Food
Family Restaurant without liquor
Theme with liquor
White Table Cloth with liquor
Specialty Food
1i. Officer Information
Provide the following information for each officer, general partner, managing member, trustee, or enterprise owner of the applying entity.
Administrative Rule R861-1A-15 requires the SSN of each individual and the EIN of each entity listed. To avoid unlawful disclosure, access
to account information is limited to those listed. If more space is needed, attach additional sheets. If changes occur, notify the Tax Commission.
Name and Title - PRINT
SSN or EIN
Home Address and City/State/Zip
Telephone Number
..........................................................................
..............................................................................
Office Use
..........................................................................
..............................................................................
Office Use
..........................................................................
..............................................................................
Office Use
..........................................................................
..............................................................................
Office Use
Office Use Only (Department of Commerce)
Section 2 – Registered Agent
The registered agent is the person or entity, residing in Utah, who is responsible for receiving all
notifications and renewal information from the Utah Department of Commerce, Division of Corporations,
concerning the DBA registered on this form.
2a. Registered Agent’s Name - PRINT
If same as Section 1, 1e, write “same” and sign below.
Agent’s Street Address (P.O. Box not acceptable)
Daytime Phone Number
City
State
Zip Code
2b. Registered Agent Signature
Date Signed
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