Form 70-001-10-8-1-000 - Registration Application Form - State Of Missisippi Page 2

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Page 2
Form 70-001-10-8-2-000 (Rev.06/10)
SECTION D: Sales/Use Tax
16. Enter Previous Owner Name, Trade Name & Account Number:
17. Where will records be maintained? (Check One)
Headquarters
Physical
Other
18.
Date business began at this location:
(Returns will be required from this date forward.)
19.
Check one of the following to describe your business location:
Owner Occupied Retail Space
Leased Retail Space
Owner's Home
Other (explain)
20.
Is your business located inside or outside the city limits?
Inside
Outside
Unknown
21.
Do you already have a use tax number?
Use Tax Number
Yes
No
22.
Have you qualified for any tax incentives?
Yes
No
If yes, please provide approved documentation from Mississippi Development Authority.
SECTION E: Withholding Tax
23. Date Mississippi taxable wages first paid
24.
Estimated monthly liability
25. Number of Mississippi Employees
26.
Are you an employee leasing company?
Yes
No
If yes, contact your District Service Office for more information.
Headquarters
27. Where will records be maintained? (Check One)
Physical
Other
SECTION F: Applicant Signature
I hereby certify that the above statements are true and correct to the best of my knowledge and belief. As indicated on this completed form,
I hereby apply for the appropriate permit(s) to engage in business. I agree to pay any and all taxes due the State of Mississippi and to
comply fully in all respects with the applicable Mississippi Tax Laws and any corresponding rules and regulations.
Title
Date
Print Name of Owner or Officer of Corporation Only
Signature of Owner or Officer of
Signature of Owner or Officer of
Signature of Owner or Officer of
Corporation
Corporation
Corporation
Listed in #15
Listed in #15
Listed in #15
If General Partnership, all General Partners must sign or if a partnership agreement is attached, only one (1) signature is required.
If limited Partnership, Managing Partner must sign. Attach sheet, if needed.
For Office Use Only - Do Not Write in this Section
Cash Bond Amt $
Date Issued
SIC Code
City Number
Also Responsible for:
M Q
A
Norms
Tax Acct No.
Tupelo Tax
Sales Tax.............................
Special City/County Tax
Occupancy Tax
Use Tax...............................
Motor Vehicle Rental Tax
Withholding Tax...................
Waste Tire Disposal Fee
Master File No.
Additional Account to be included in Master File Number:
Yes
No
Approved:
Agent's Number
Master File Agent's Signature
Agent's Signature
Date

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