Registration For Oregon Emergency Communications Tax Form

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FOR REVENUE USE ONLY
Date Received
REGISTRATION FOR OREGON
O R E G O N
BIN
EMERGENCY COMMUNICATIONS TAX
D E PA R T M E N T
O F R E V E N U E
Business Name
Federal Identification Number
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
Individual
Partnership
Corporation
Other
Names of Owner, Partner, or Corporation Officers:
Name
Street Address
City, State, ZIP Code
Social Security Number
Contact Person
Telephone Number
Nature of Business
Telecommunications Utility
Cellular Telephone Company
Other
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
Net amount of tax billed during the quarter (gross amount billed less adjustments)
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. 2-02) Web
EMERGENCY COMM. TAX
Mail to:
OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910

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