Form Crf-002 - State Tax Registration Application Page 2
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SECTION 4 - Owners, Partners, Officers and Members
1.* Name
A.* Social Security (SSN) / Individual Taxpayer Identification Number (ITIN)
Application will not be processed
unless the social security number of an owner, officers, managing members or both
partners is included. Reg.560-1-1.18
B. Check all that apply: Effective Date
Effective Date
Effective Date
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C. Home address (street)
City / Town
County
State
Zip Code + 4
2.* Name
A.* Social Security (SSN) / Individual Taxpayer Identification Number (ITIN)
Application will not be processed
unless the social security number of an owner, officers, managing
members or both partners is included. Reg.560-1-1.18
B. Check all that apply: Effective Date
Effective Date
Effective Date
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C. Home address (street)
City / Town
County
State
Zip Code + 4
SECTION 5 - Nature of Business
1.* Nature of Business (If your business is a combination of two or more, list approximate percentages of receipts.)
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Retail ____%
Manufacturing ____%
Services (Specify) ____%
Wholesale _____%
Construction ____%
Other ____%
2.* What product will you sell or what taxable service will you provide?
Will you sell Motor Fuel / Gasoline?
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Yes
No
3. . If you know your NAICS code, enter here______________________ (6 digits)
SECTION 6 - Employers Withholding Information
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1.* Will your business have employees?
Yes
No
Enter the other business reporting and paying these taxes:
(If the answer above is No, then proceed to Section 7)
2. Who will be responsible for filing and remitting the payroll taxes
Name
for your employees?
Withholding Account
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Your Business
Other
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Payroll Service / Bureau
4. How many employees do you have or will have?
3. Do you expect to withhold more than $200 per month?
5. What is the date on which wages will be first paid to employees?
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(mm/dd/yyyy)
Yes
No
SECTION 7 - Authorized Signature/Contact Information
I (WE), THE UNDERSIGNED, DECLARE UNDER PENALTIES OF PERJURY THAT I (WE) HAVE EXAMINED THIS
APPLICATION AND TO THE BEST OF MY (OUR) KNOWLEDGE IT IS TRUE, CORRECT AND COMPLETE.
Authorized Signature: _______________________________________
Title:___________________________________
Print / Type Name:__________________________________________
Phone #:________________________________
Print / Type Preparer's Name:________________________________
Title:___________________________________
Phone#:__________________________________________________
Fax: ____________________________________
Email ______________________________________________
CRF - 002 - Registration Application 2
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