Form Com: 101 - Combined Registration/application
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2COM: 101
10/15
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Combined registration/ Application
ACCOUNT NUMBER
PLEASE SEE THE INSTRUCTIONS BEFORE COMPLETING FORM
Applicant Information:
LEGAL NAME OF APPLICANT, EMPLOYER, CORPORATION, PARTNERSHIP, TRUST, ETC.
TRADE NAME, DBA NAME(S) OR DIVISION (IF DIFFERENT FROM ABOVE)
BUSINESS LOCATION
CITY
STATE
ZIP
COUNTY
CITY LIMITS PJ
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY
STATE
ZIP
BUSINESS TELEPHONE NUMBER
FAX NUMBER
CONTACT NAME
CONTACT TELEPHONE NUMBER
EMAIL ADDRESS
ADDRESS WHERE BUSINESS RECORDS ARE KEPT IF DIFFERENT FROM BUSINESS ADDRESS
CITY
STATE
ZIP
EFFECTIVE DATE
NAICS CODE:
FEDERAL EMPLOYER ID NUMBER (FEIN):
Section A:
TYPE OF OWNERSHIP: (PROOF MAY BE REQUIRED)
Proprietorship
Limited Liability Partnership
Professional Association
Multi Member LLC
Governmental Agency
Partnership
Corporation
Single Member LLC – Have you filed your Form 8832 with the IRS?
Yes
No
Other
CORPORATE REGISTRATION OR OTHER BUSINESS TYPE CHARTER NUMBER:
PRIMARY STATE OF REGISTRATION:
NATURE OF BUSINESS:
Manufacturing
Service
Wholesale
Contractor
Retail
Both Wholesale/Retail
Other
BUSINESS ACTIVITY:
Identify Current Owners, Partners, Corporate Officers, Members, Employers, or Trustees Including Social Security Numbers or Federal ID Numbers:
PRIMARY NAME/LAST NAME
FIRST NAME
PRIMARY NAME/LAST NAME
FIRST NAME
TITLE
SOCIAL SECURITY NUMBER
FEIN
TITLE
SOCIAL SECURITY NUMBER
FEIN
HOME ADDRESS
HOME ADDRESS
CITY
STATE
ZIP
CITY
STATE
ZIP
HOME TELEPHONE NUMBER
HOME TELEPHONE NUMBER
Name, Address, Telephone Number, and Account Number of Previous Owner(s): (Not For Withholding Tax)
PRIMARY NAME/LAST NAME
FIRST NAME
HOME TELEPHONE NUMBER
ACCOUNT NUMBER
HOME ADDRESS
CITY
STATE
ZIP
TAXES TO REGISTER FOR ON THIS APPLICATION:
State Sales Tax
State Sellers Use Tax
Mobile Communication Services Tax
Pharmaceutical Providers Tax
State Administered Local Sales, Use,
(Applicant must fill out Section C)
Utility Privilege Tax
AL Nursing Home Privilege Tax
Rental or Leasing, and Lodgings Taxes
State Rental or Leasing Tax
2.2 Utility Tax
Prepaid Wireless 9-1-1 Service Charge
State Consumers Use Tax
State Lodging Tax
Utility Excise Tax
Income Withholding Tax
Section B: Income Tax Withholding (Employee eligibility verification required through E-Verify – See instructions on page 4)
1 Date of First Payroll Withholding (month / day / year): _________________________
2 Since the Date on Line 1, are you continuing to withhold Alabama Income Tax?
Yes
No If no, last payroll date (month / day / year): _______________________
3 Total estimated annual number of employees in Alabama: _______________________
4 Employer’s Return of Alabama Income Tax Withheld: Period covered from (month / day / year): _____________________________ to _____________________________
Alabama Income Tax Withheld: $__________________________ (attach remittance)
NOTE: Individual owners and partnerships which do not have employees should not apply for an Alabama withholding tax account number.
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.
A. APPLICANT NAME/LAST NAME*
FIRST NAME
TITLE
DATE
B. APPLICANT NAME/LAST NAME*
FIRST NAME
TITLE
DATE
C. APPLICANT NAME/LAST NAME*
FIRST NAME
TITLE
DATE
*Name of authorized preparer.
Mail completed application and any initial tax due to: Alabama Department of Revenue, Business Registration Unit, P.O. Box 327100, Montgomery, AL 36132-7100
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Parent category: Financial