Form Com: 101 - Combined Registration/application/change Form

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COM: 101

LABAMA

EPARTMENT OF

EVENUE

5/02

Combined Registration/ Application/Change Form

PLEASE SEE INSTRUCTIONS ON BACK PAGE BEFORE COMPLETING FORM

WITHHOLDING NUMBER

ACCOUNT NUMBER

FOR OFFICE USE ONLY

AGGREGATE CHAIN NUMBER

TYPE OR PRINT ALL INFORMATION ON THIS APPLICATION

SECTION A: Business Information

(all applicants must complete this section – see instructions, page 4)

Taxes to register for on this application:

CHECK APPROPRIATE BOX(ES) — NO FEE REQUIRED

Sales Tax

Rental Tax

Lodgings Tax

Sellers Use Tax

Consumers Use Tax

Income Tax Withholding

Reason for application:

New Application

Reopen

Name Change /

Address Change – Date of change: _______/_______/_______

Additional Location

Name and business location address:

2a Mailing address:

(Where you want to have your returns mailed and/or CPA, attorney, or other

The location where sales will take place must be exact street number, or if on a highway or rural route,

agent’s name and address if you want your returns sent there. Please attach

give details as to location (a P.O. Box will not suffice).

additional sheets listing any other alternate addresses and which tax returns you

wish sent to each address if necessary.)

LEGAL NAME OF APPLICANT, EMPLOYER, CORPORATION, PARTNERSHIP, TRUST, ETC.

TRADE NAME OR DIVISION (IF DIFFERENT FROM ABOVE)

CPA, ATTORNEY, OR OTHER AGENT’S NAME (IF YOU HAVE ONE)

ADDRESS

CITY

COUNTY

STATE

ZIP

CITY

COUNTY

STATE

ZIP

(

)

PHONE (INCLUDE AREA CODE)

PERSON TO CONTACT

E-MAIL ADDRESS

2b Federal Employer ID Number:

THIS IS NOT YOUR SOCIAL SECURITY NUMBER, SEE BLOCK 6

Location of business: (For sales, lodgings, sellers use, and consumers use tax only)

CHECK ONE OF THE FOLLOWING BOXES FOR LOCATION OF BUSINESS

Corporate Limits of City

Police Jurisdiction

Outside Corporate Limits and Police Jurisdiction

Complete the enclosed “State Administered City and County List” for all locations where you anticipate transacting or soliciting business.

Type of ownership:

CHECK APPROPRIATE BOX

Proprietorship

Partnership

Corporation

Professional Association

Limited Liability Company

Limited Liability Partnership

Governmental Agency

Other ___________________________________________________________

** For any registration, name change, or merger, corporations must attach one of the following: copy of the certified Certificate of Incorporation,

Amended Certificate of Incorporation, Certificate of Authority or Articles of Incorporation. Limited Liability Companies/Partnerships must pro-

vide a copy of the certified Articles of Organization, including members’ names and Social Security Numbers or Federal ID Numbers listed.

Professional Corporations/Associations must provide copy of certified Articles of Association. If members or partners are added or removed,

you must notify the Department of Revenue in writing and include supporting documentation.

ALL applicants must COMPLETE and SIGN this section.

The statements contained in this application and any accompanying schedules are correct to the best knowledge and belief of the undersigned who is duly

authorized to sign this application.

Signature of owner or all partners is required. If a corporate application, an officer must sign. If a Partnership or Limited Liability Partnership applica-

tion, all partners must sign (attach additional sheet if necessary). If a Limited Liability Company a member must sign. Signatures of accountants, cer-

tified public accountants, or other agents will not be accepted. Signature stamps, photocopies or fax copies of applications or unsigned applications

will not be accepted.

SIGNED

TITLE

DATE (MONTH / DAY / YEAR)

SIGNED

TITLE

DATE (MONTH / DAY / YEAR)

SIGNED

TITLE

DATE (MONTH / DAY / YEAR)