Form 150-211-055 - Combined Employer'S Registration
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COMBINED EMPLOYER’S REGISTRATION
FOR AGENCY USE ONLY
BIN
Date received
• We cannot issue a Business Identification Number (BIN)
if your registration is incomplete.
E/R code
County
NAICS
• Be sure to read the instructions on the back.
• You must fill in the date employees were first paid.
• Please type or print. Press hard if printing.
Business name
Type of Ownership (check one):
Corporation
Limited Liability Part.
Pension and Annuity
Assumed business name
Government—Federal
Non-profit 501(c)(3)
Political Campaign
(
Government—Local
attach federal exemption)
Sub-chapter S Corp
Federal EIN
Business telephone number
Government—State
Other Non-profit
Other
(describe below):
Ext.
Individual
Partnership—General
Person at business authorized to discuss your payroll acount with us
Limited Liability Co.
Partnership—Limited
Ext.
Check if Construction Contractors Board (CCB) only
Business mailing address
Nature and principal products of your business (i.e., retail—men’s clothing;
services—janitorial; etc.). Be specific.
City
State
ZIP code
Check if any employees are:
E-mail address
Fax number
Agricultural
Working on fishing vessels
Domestic (in-home workers)
Does any domestic worker request withholding?
Yes
No
Physical location of business in Oregon—street address
Type of return to be filed (see instructions)
OQ (Oregon Quarterly)
WA (Federal 943 filers only)
OA (Domestic)
City
State
ZIP code
Approximate number of employees
WITHHOLDING
TAX
Do you have any other locations in Oregon? (see instructions for listing all locations)
Date employees were/will first be paid for work in Oregon
Must be
Yes
No
Month _________ Day ________ Year_________
completed
Offsite payroll service, accountant, or bookkeeper (attach Power of Attorney)
Check if any employees work in these areas (see instructions)
Tri-Met (Portland and surrounding metropolitan areas)
TRANSIT
Contact person at the offsite payroll service, accountant, or bookkeeper
LTD (Eugene and Springfield areas)
TAX
Phone
Date employees first paid for services performed within district(s)
Mailing address for offsite payroll service (send:
forms
billings to this address?)
Tri-Met _________________ LTD _________________
C/O
In what calendar quarter did/will your payroll first exceed $225?
City
State
ZIP code
Exceptions: $20,000 Agricultural $1000 Domestic
(see instructions)
UNEMPLOYMENT
Quarter ___________ Year ___________
TAX
Bank reference/branch address
Date first Oregon employee was hired
Month _____ Day _____ Year _____
Date of acquisition
Business ID No.
Did you acquire all the Oregon business operations of an ongoing business?
Yes
No
If no, but you acquired part of an ongoing business, see the instructions on partial transfers
List acquired business name, previous owner, and telephone number
IDENTIFICATION OF OWNERS, PARTNERS, CORPORATE OFFICERS, ETC.
(List additional owners on a separate sheet and attach to this form)
Social Security number
Federal EIN
Telephone number
Social Security number
Federal EIN
Telephone number
Name
Name
Home address
Home address
City
State
ZIP Code
City
State
ZIP Code
Responsible for:
Responsible for:
Filing tax returns
Paying taxes
Hiring/firing
Filing tax returns
Paying taxes
Hiring/firing
Determining which creditors to pay first
Determining which creditors to pay first
AUTHORIZATION
I certify the above statements to be true and correct. I authorize the Employment Department and the Department of Revenue to verify any of the above
information with regard to this business. I will notify each agency if there is a change or cancellation of the above authorized representative.
Signature
Date
Signature
Date
X
X
150-211-055 (Rev. 6-03)
OREGON DEPARTMENT OF REVENUE
Mail white and yellow copies to:
PO BOX 14800
Retain pink copy for your records.
SALEM OR 97309-0920
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