Form St-1s - Application For Service Vendor'S License (2001)
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1ST-1S
FOR STATE USE ONLY
(Rev. 7/01)
Account Number Assigned
Check Digit
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P.O. Box 182215
Columbus, OH 43218-2215
l
FAX: (614) 387-1851
Effective Date Filing Frequency
A
S
V
'
L
PPLICATION FOR
ERVICE
ENDOR
S
ICENSE
Social Security Number
Ohio Corporate Charter Number
Federal Employer Identification Number
Please print.
If you are a Foreign Corporation, give Ohio Certificate Number.
Ohio Certificate Number
c
c
(30) Corporation c
(40) Association c
1.Check type of ownership: (10) Sole Owner
(20) Partnership
c
c
c
(80) LTD c
(100) Business Trust c
(50) LLC
(60) Fiduciary
(70) LLP
m m
d
d
y
y
2. When did you or will you begin providing the taxable service in the State of Ohio?
3. Provide NAICS Code and state nature of business activity.
See page 2.
NAICS Code
_____________________________________________________________________________________________________
4. Legal name ___________________________________________________________________________________________
5. Trade name or DBA_____________________________________________________________________________________
if partnership, list names
6. Primary address ________________________________________________________________________________________
(home/office address of corporation, sole owner or partnership)
city
state
zip
(
)
(
)
(home/office phone no.)
(home/office fax number)
7. Mailing address_______________________________________________________________________________________
(if different than above)
city
state
zip
8. List location of all permanent places of business in Ohio, if applicable, and provide vendor's license numbers.
–
__________________________________________________________
Vendor's License Number
name
street
city
–
__________________________________________________________
Vendor's License Number
name
street
city
c
c
9. How much sales tax do you anticipate collecting each month?
(06) Less than $200
(01) $200 or greater
10. If this application is for a new registration due to change in ownership, please list the old account number.
–
11. If you operate as a corporation or partnership, list appropriate names, addresses and social security numbers below.
Social Security Number
–
–
President/Partner_____________________________________________________________
name
street
city
state
zip
Social Security Number
–
–
Vice-Pres/Partner_____________________________________________________________
–
–
name
street
city
state
zip
Social Security Number
–
–
Secy/Treas/Partner____________________________________________________________
name
street
city
state
zip
I hereby declare the above to be true and correct to the best of my knowledge and belief.
_____________________________________
___________________________________________________
date
signature of owner or officer of company
Fee for this license – $25.00
.
(made payable to Treasurer of State)
Send the original application and $25.00 fee to:
Ohio Department of Taxation, Registration Unit, P.O. Box 182215, Columbus, OH 43218-2215.
Retain a copy for your records.
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