Form Reg-1 - Business Taxes Registration Application Page 2
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6DRS USE ONLY TAX REGISTRATION NUMBER
For DRS Use Only
–
5. Business Name and Address
REC
AD
Organization Name (Enter Name of Sole Proprietor, Partnership, Corporation, or LLC)
FEIN or SSN
Business Trade Name
Business Location: Enter physical address of the business. A post office box or rural route number is not acceptable.
Home-based businesses and flea market or craft show vendors must enter home address.
Address Line 1
Address Line 2
City
State
ZIP Code
Mailing Address Line 1 (Street or PO Box)
Address Line 2
City
State
ZIP Code
Business Telephone
Bank Name
(
)
6. List all Owners, Partners, Corporate Officers, or LLC Members
(attach a separate sheet if needed)
Name (Last, First, MI)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
SSN
Date of Birth
Telephone Number
Bank Name
(
)
/
/
Name (Last, First, MI)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
SSN
Date of Birth
Telephone Number
Bank Name
(
)
/
/
Name (Last, First, MI)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
SSN
Date of Birth
Telephone Number
Bank Name
(
)
/
/
Name (Last, First, MI)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
SSN
Date of Birth
Telephone Number
Bank Name
/
/
(
)
For Department Use Only
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
Tax
Trans
Registration Date
NAICS
Type of Organization
State
Legal Date
Total Remitted
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
00
/
/
/
/
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
Tax
Trans
Registration Date
Start Date
Bus. Town
Source
Liability
FileCode
Type Filing
Mail
Security #
Security Amount
Fee Remitted
/
/
/
/
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
Tax
Trans
Registration Date
Start Date
Bus. Town
Source
FileCode
Penalty Remit
Total Remitted
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
63
/
/
/
/
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
Tax
Trans
Registration Date
Start Date
Bus. Town
Source
Liability
FileCode
Type Fil
Mail Fiscal Year
Security #
Security Amt
Fee Remitted
/
/
/
/
Tax
Trans
Registration Date
Start Date
Bus. Town
Source
Liability
FileCode
Security #
Security Date
Security Amount
30
/
/
/
/
/
/
Tax
Trans
Registration Date
Start Date
Bus. Town
Source
Filing
Payment Schedule
Type Filing
Mail
PCC
Security #
Security Amount
/
/
/
/
Page 4 of 8
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Parent category: Financial