Form 21884 - Application To Obtain Contractor'S Request For Clearance Form - State Of North Dakota

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North Dakota Office of State Tax Commissioner

Application to Obtain Contractor's Request

For Clearance

FOR OFFICE USE ONLY

Pursuant to North Dakota Century Code § 43-07-11.1, as amended, a request for Income, Sales and Use Tax Clearance

Application is made on behalf of:

1. Taxpayer Legal Name

2. Federal Employer I.D. Number (FEIN)

or Social Security Number

3. Doing Business As Name (if different from line 1)

4. Business Phone

State

Zip Code

City

5. Mailing Address

6. Organization Type

General Partnership

LLC

Corporation

Sole Proprietorship

LLP

Limited Partnership

Resident

Nonresident

8. If incorporated, Date of Incorporation ________________________________________

9. Description of business (list all types of activity)

10. Has business activities been conducted in North Dakota anytime during the past three years?

Yes

11. Do you have employees for which you have a withholding obligation?

Yes

12. Are you making sales on a regular ongoing basis?

Yes

13. Application must be signed by authorized individual:

Date:

Signature:

(Authorized Individual)

Print name:

Title:

Phone No:

I declare under the penalties of North Dakota Century Code ch. 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental

matter, that this application, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true,

correct and complete application.

For Office Use Only

Mail to: Office of State Tax Commissioner

Contact: Fax: (701)328-0332

Business Registration

Phone: (701)328-1241 - Sales

600 E. Boulevard Ave., Dept. 127

Web site:

Bismarck, ND 58505-0599

Email: taxregistration@nd.gov

21884 (Revised 11/09)