In-City Business Registration Questionnaire
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1
2CITY OF ALLENTOWN
IN-CITY BUSINESS REGISTRATION QUESTIONNAIRE
You are:
Changing an existing account (OR)
Registering a new business EFFECTIVE DATE ___________________
GENERAL INSTRUCTIONS: Complete all sections of the questionnaire, answering all questions in full. All registrants must complete Signature Section C. Mail
completed form to: City of Allentown, Bureau of Revenue & Audit, 435 Hamilton Street, Room 215, Allentown, PA 18101. Any questions, please call 610-437-7507.
An application fee of $35.00 must accompany the Business Registration Questionnaire.
Section A: This section must be completed for an Incorporated business or by persons who are Self-Employed and by each Partner of an
unincorporated business. Additional copies of this form are available upon request, and on-line at:
Business Name
Federal EIN Number
Legal Name (if different than Business Name)
Business Web Address
Sole Proprietor or Partner Name
Social Security Number
Physical Business Address (Do not use PO Box)
City
State
Zip
Business Phone
Allentown
PA
Contact Person
E-mail Address
Mailing Address for
ALL Business Related
Street or PO Box
City
State
Zip
Forms
Indicate Type of Entity:
Business Classification: [ ] Wholesale
[ ] Retail
[ ] Service
[ ] Manufacturing
[ ] Sole Proprietorship
Nature of Business: (detailed description)
[ ] Partnership
[ ] Corporation
[ ] S-Corp
[ ] LLC
[ ] Other
LIST PRINCIPLE OWNERS, PARTNERS OR OFFICERS
Name & Title
Home Address
Social Security No.
Home Phone
City or Township/School District where you reside?
Do you, or will you, have amusement devices?
Date business incorporated
State of Incorporation
[ ] NO
[ ] YES, # of devices ________
No. of employees (if Sole Proprietor, do not include yourself in this number)
LIST ALL OTHER CITY OF ALLENTOWN BUSINESS NAMES AND ACCOUNT NUMBERS
Business Name
Account No. (QW,MW,EW,SP,RE)
Section B: this section MUST BE completed for ALL businesses operating in the City of Allentown
Name:
Telephone No.
Tax Preparer
Address:
Information
City:
State
Zip
Name:
Telephone No.
Principle Bank
Address:
Information
City:
State
Zip
Section C:
I hereby certify that the above information and statements are true and correct. I understand that approval for the above business
is contingent upon my compliance with the following departments: Bureau of Revenue & Audit, Zoning, Recycling, Fire and Health
(where necessary). I also understand that it is my responsibility to notify the City of Allentown in writing, or on forms designated by
the City, if any of the above information changes, or if my business closes.
Signature
Title
Date
Non-Profit Organizations: The City
requires a copy of your 501C (IRS
EDEN Customer #
Business Acct #
non-profit letter)
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