Lodging Tax Registration - State Of Oregon Form 2003
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1FOR OFFICE USE ONLY
Clear Form
STATE OF OREGON
O R E G O N
Date Received
D E PA R T M E N T
LODGING TAX REGISTRATION
O F R E V E N U E
Business Identification Number
• Print or type all information.
Business Name (including DBAs)
Federal Identification Number
Business Location Address
City
State
ZIP Code
County
Mailing Address
City
State
ZIP Code
Business Telephone Number
(
)
Location of Business Records (if different from above)
City
State
ZIP Code
Records Telephone Number
(
)
Contact Person
Telephone Number
Business Start Date
(
)
Type of Organization
Type of Accommodation (please check all that apply)
Individual
Hotel—
RV Sites—
LLC
Number of units:
Number of units:
Partnership
Government
Motel—
Campground—
Number of units:
Number of units:
Corporation
Bed & Breakfast—
Other:
—
Number of units:
Number of units:
Name of Bank
Branch Name
Street Address
City, State, ZIP Code
Names of Owners, Partners, or Corporation Officers. Please print clearly (use additional sheets if necessary):
Name
Street Address
City, State, ZIP Code
Social Security Number
FEDERAL PRIVACY ACT INFORMATION
Under the general authority of OAR 150-305.100, the Social Security numbers of all company officers or owners must be included in
this registration. This information will be used primarily by the Oregon Department of Revenue for identification and compliance
purposes in the administration of the State of Oregon lodging tax.
DECLARATION
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
Social Security Number
Date
X
PRINT Name Signed Above
Title
Telephone Number
(
)
Return your completed registration form to the Department of Revenue.
Mail to: OREGON DEPARTMENT OF REVENUE
PO BOX 14110
SALEM OR 97309-0910
150-604-001 (Rev. 10-03)
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