Form S55 (1006) - Supplemental Registration printable pdf download

Form S55 (1006) - Supplemental Registration

SUPPLEMENTAL REGISTRATION

Business Identification No. (BIN)

Business Name:

Telephone Number:

Mailing Address:

City:

State:

Zip:

UPDATED INFORMATION OF OWNERS, PARTNERS, CORPORATE OFFICERS, ETC.

Name (give full name)

Social Security

Home Address & Phone Number

Title

Number

Did you acquire an ongoing business?

Yes

Did you acquire all business operations of a previous owner?

Yes

If no, please submit a written explanation (using the back of this form or attach an additional sheet).

Did you acquire or hire any of the previous owner’s employees?

Yes

If “Yes” how many employees did you hire or acquire? ______________

Business Name and Address of Acquired Business:

Business Identification No. (Bin)

Date of Acquisition

Bank information/Accounting/Bookkeeper

Business Phone Number:

I certify the above statements to be true and correct. I authorize the Employment Department to verify any of the above

information with regard to this business. I will notify the agency if there are any changes to the above business.

Signature of Acquiring Owner

Date

Mail To: Employment Department; Tax Section

875 Union Street, NE; Salem, OR 97311

Fax To: 503-947-1700

Form S55 (1006)

Form S55 (1006) - Supplemental Registration