FOR AGENCY USE ONLY
COMBINED EMPLOYER’S REGISTRATION
BIN
Date received
E/R code
County
SIC
• Be sure to read the instructions on the back.
• We cannot issue a Business Identification Number (BIN) if your registration is incomplete.
• You must fill in the date employees were first paid.
(G) Government—State
• See instructions for information on Workers’ Compensation Insurance.
Type of Ownership (circle one):
(O)
Government—Local
(I)
Individual
(N)
Non-profit 501 (c)(3)
Business name
(S)
Sub-chapter S Corp
(M)
Limited Liability Part.
(T)
Pension and Annuity
(C)
Corporation
(P)
Partnership—General
(L)
Limited Liability Company
Other (describe below):
(Q)
Partnership—Limited
(F)
Government—Federal
Federal ID number
Business telephone number
Nature and principle products of your business (i.e., retail—men’s clothing;
services—janitorial; etc.). Be specific.
(
)
Ext.
Person at business authorized to discuss your payroll acount with us
(
)
Ext.
Business mailing address
Check if any employees are:
Agricultural
Working on fishing vessels
Domestic
Does any domestic worker request withholding?
Yes
No
State
ZIP Code
City
Type of return to be filed (see instructions)
OQ
WA (Federal 943 filers only)
Physical location of business in Oregon—street address (if other than mailing)
Date employees were/will first be paid for work in Oregon (this
WITHHOLDING
box must be completed) Month _____ Day _____ Year_____
TAX
City
State
ZIP Code
Approximate number of employees
Do you have any other locations in Oregon? (see instructions)
Check if any employees work in these areas (see instructions)
Yes
No
Tri-Met (Portland and surrounding metropolitan areas)
TRANSIT
Offsite payroll service, accountant, or bookkeeper
LTD (Eugene and Springfield areas)
TAX
Date employees first paid for services performed within district(s)
Contact person at the offsite payroll service, accountant, or bookkeeper
Tri-Met _________________
LTD _________________
(
)
Phone
In what calendar quarter did/will your payroll first exceed $225?
Mailing address for offsite payroll service (send:
forms
billings to this address?)
Exceptions: $1000 Domestic
$20,000 Agricultural (see instructions)
UNEMPLOYMENT
C/O
Quarter ___________ Year ___________
TAX
City
State
ZIP Code
Date first Oregon employee was hired
Month _____ Day _____ Year _____
Bank reference/branch address
Date of acquisition Business ID No.
Yes
Did you acquire all the Oregon business
operations of an ongoing business?
No
List acquired business name and previous owner
IDENTIFICATION OF OWNERS, PARTNERS, CORPORATE OFFICERS, ETC.
(List additional owners on a separate sheet and attach to this form)
Social Security number
Telephone number
Social Security number
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
Social Security number
Telephone number
Social Security number
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 and the Department of Revenue 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
Mail white and yellow copies to:
OREGON DEPARTMENT OF REVENUE
150-211-055 (Rev. 8-98)
PO BOX 14800
Retain pink copy for your records.
SALEM OR 97309-0920