Form Ra 1 - Resort Area Gross Receipts Excise Tax - Application For Registration
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STATE OF OHIO
FORM RA 1
DEPARTMENT OF TAXATION
h
P. O. BOX 530
ACCOUNT NUMBER ASSIGNED
COLUMBUS, OH 43216-0530
FM
EFFECTIVE DATE
Kelleys Island
RESORT AREA GROSS RECEIPTS EXCISE TAX
Village of Put-In-Bay
Township of Put-In-Bay
APPLICATION FOR REGISTRATION
Section 5739.103 of the Ohio Revised Code requires registration with the Tax Commissioner for those who engage in business as described in Division
(B)(1) or (2) of Section 5739.101 of the Revised Code.
I/we herewith make application for registration with the Tax Commissioner. (For sole owner, print individuals name; for partnership, print full names of
all partners; for corporation, print corporation's name and charter number. If a foreign corporation, print the certificate number issued by the Secretary of
State authorizing transaction of business in Ohio pursuant to Section 1703.01, O.R.C.).
NAME
CHARTER #
__________________________________________________________________________________________________
________________
DBA (TRADE NAME)
_________________________________________________________________________________________________________________
LOCATION OF BUSINESS
____________________________________________________________________________________________________________
STREET
CITY
STATE
ZIP
MAILING ADDRESS
__________________________________________________________________________________________________________________
STREET
CITY
STATE
ZIP
WINTER INFORMATION
_____________________________________________________________________________________________________________
STREET
CITY
STATE
ZIP
TELEPHONE NUMBER(s) ______________________________
_____________________________ _________________________________
(Please indicate if Business, Home, Fax, and/or Alternate Number)
VENDOR'S LICENSE NO. ______________________ DESCRIBE BUSINESS ACTIVITY ____________________________________________
WHEN DID YOU OR WILL YOU BEGIN ENGAGING IN BUSINESS _____________________________________________________________
SOCIAL SECURITY NUMBER OR FEDERAL EMPLOYER IDENTIFICATION NUMBER
FEDERAL EMPLOYER IDENTIFICATION NUMBER
SOCIAL SECURITY
TYPE OF OWNERSHIP - CHECK ONE
CORPORATION
SOLE OWNER
PARTNERSHIP
FIDUCIARY
ASSOCIATION
BUSINESS TRUST
CORPORATION INFORMATION: OFFICER'S NAMES AND ADDRESSES
PRESIDENT_____________________________________________________________________________________________________________
NAME
STREET
CITY
STATE
ZIP
VICE-PRES. ___________________________________________________________________________________________________________
NAME
STREET
CITY
STATE
ZIP
SECY/TREAS.___________________________________________________________________________________________________________
NAME
STREET
CITY
STATE
ZIP
I DECLARE THE ABOVE TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
______________________________________________________________________________ ________________________________________
SIGNATURE OF VENDOR OR AGENT
DATE
Send original application to the above address. Telephone: 888-405-4039
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