Form 150-211-055 - Combined Employer'S Registration
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1Clear Form
Combined Employer’s Registration
For agency use only
BIN
See instructions below
You can register online with the Oregon Business Registry (OBR) at https://secure.sos.state.or.us/cbrmanager/
*
Business name
Type of ownership (check one):
Corporation
LLC (Limited Liability Co.)
Government–Local
Sub-chapter S Corp.
recognized by IRS as a:
Government–State
Assumed business name
Sole Prop. (Individual)
Corp, or
Government–Federal
LLP (Limited Liability Part.)
Individual
Political Campaign
(Sole Prop.), or
*
Partnership—General
Partnership
Other
Federal employer identification number (FEIN)
(describe below):
Partnership—Limited
Non-profit 501(c)(3)
___________________
(attach federal exemption)
Pension and Annuity
___________________
Business telephone number
Fax number
Trust / Estate
Other Nonprofit
___________________
Ext.
Contact person authorized to discuss your payroll account with us
Recognized Indian Tribe
Nature and principal products of your business (i.e., retail—men’s clothing;
services—janitorial; etc.). Be specific.
Contact’s telephone number
Ext.
Check if any employees are:
Courtesy Withholding
Business mailing address
Agricultural
Working on fishing vessels
Domestic (in-home workers)
Does any domestic worker request withholding?
Yes
No
City
State
ZIP code
Type of return to be filed (see instructions)
OQ (Oregon Quarterly)
WA (Federal 943 filers only)
OA (Domestic)
E-mail address
Check here to authorize us to initiate e-mail exchange of tax information.
Enter number of employees (approximate)
Withholding
LLC Member ______ Owner/Officer ______ Employees ______
Tax
*
Physical address where work is performed in Oregon
Employee home address
*
Date employees were/will first be paid for work in Oregon
Must be
Month _________ Day ________ Year _______________
completed
➙
City
State
ZIP code
Are employees working in these areas? (see instructions)
TriMet (Portland and surrounding metropolitan areas)
Transit
Do you have any other locations in Oregon?
LTD (Eugene and Springfield areas)
Tax
Date employees first paid for services performed within district(s)
No
Yes, list additional locations on a separate sheet & attach to this form
TriMet __________________ LTD __________________
Off site payroll service, accountant, or bookkeeper (attach Power of Attorney form)
In what calendar quarter did/will your payroll first exceed $1,000
or $20,000 agricultural labor? (see instructions)
Contact person at the off site payroll service, accountant, or bookkeeper
Quarter ___________ Year_______________
Unemployment
Tax
Telephone No.
Date first Oregon employee was/will be hired
Mailing address for off site payroll service (send:
forms
billings to this address?)
Month _________ Day ________ Year _______________
Employees need to be covered by a workers’ compensation (WC) policy?
C/O
Yes
No, but I choose to have coverage
City
State
ZIP code
Workers’
(Check the reason you don’t need a WC policy)
Benefit Fund
No, employees are covered by federal WC
Assessment
Bank reference/branch address
No, only owners/corporate officers
No, other
_______________________________________
(explain)
Date of acquisition
FEIN or BIN of acquired business
Did you acquire/transfer all
Yes
No or part
Yes
No of the Oregon business
operations of an ongoing business? How many employees transferred? _________________
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
Social Security number
FEIN
Telephone number
FEIN
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, the Department of Revenue, and the Department of Consumer & Business
Services 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
* Must be filled in as required by
Fax to: 503-947-1528 or Mail to: Oregon Employment Department
OAR 150-305.100.
875 Union St NE Rm 107
Salem OR 97311
Retain a copy for your records.
150-211-055 (Rev. 12-15)
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