Form Crf-002 - State Tax Registration Application Page 2
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2(Please Read Instructions Before Completing)
OWNERSHIP / RELATIONSHIP SECTION
(This section MUST be completed for your application to be accepted.)
15. CHECK ALL THAT APPLY
Owner
Parent Company
Manager
Related Business
Partner
Shareholder
Tobacco Licensee
Motor Fuel Supplier
Officer
Alcohol Licensee
Tobacco Distributor
Managing Member
A
BUSINESS NAME
STI or LICENSE NO.
B
GA SALES TAX NO.
GA WITHHOLDING TAX NO.
C
LAST NAME
FIRST
M.I.
TITLE
SOCIAL SECURITY NUMBER
Application will not be processed unless the social security number of an owner,
officer, both partners or a managing member is included on this line Reg 560-1-1.18
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
16. CHECK ALL THAT APPLY
Owner
Parent Company
Manager
Related Business
Partner
Shareholder
Tobacco Licensee
Motor Fuel Supplier
Officer
Alcohol Licensee
Tobacco Distributor
Managing Member
A
BUSINESS NAME
STI or LICENSE NO.
B
GA SALES TAX NO.
GA WITHHOLDING TAX NO.
C
LAST NAME
FIRST
M.I. TITLE
SOCIAL SECURITY NUMBER
Application will not be processed unless the social security number of an owner,
officer, both partners or a managing member is included on this line Reg 560-1-1.18
D
ADDRESS
E
CITY
STATE
ZIP
COUNTY
COUNTRY
PHONE
(TO REPORT ADDITIONAL RELATIONSHIPS, USE FORM CRF-004)
SALES AND TAX SECTION
17. NATURE OF BUSINESS (If combination of two or more, list approximate percentages of receipts. Must equal 100%.)
Retail
_______%
Services
______%
Manufacturing __________ %
Mining
_________%
Construction
_______%
Processing ______%
Other
__________ %
Wholesale _________%
18. WHAT KIND OF BUSINESS WILL YOU OPERATE? (Be specific as to the product sold or service provided.)
19. WILL YOU SELL ALCOHOLIC BEVERAGES?
YES
NO
20. WILL YOU SELL RETAIL TOBACCO PRODUCTS?
YES
NO
21. WILL YOU SELL GASOLINE AND / OR MOTOR FUEL?
YES
NO
If “Yes”, please specify the name of the dealer responsible for paying the tax on gasoline and / or motor fuel sales, if other than yourself.
NAME
SALES TAX NO.
22. WHEN DID OR WILL YOU START SELLING OR PURCHASING ITEMS SUBJECT TO SALES TAX? Date
/
/
If your business will have no employees, skip the next section and complete the signature section below
WITHHOLDING TAX SECTION
23. WHO WILL BE RESPONSIBLE FOR FILING AND REMITTING THE PAYROLL TAXES FOR YOUR EMPLOYEES?
Applicant
Payroll Service
Paid under an existing GA Withholding Account
If “existing account”, please complete section below on the business responsible for paying these taxes.
NAME
GA WITHHOLDING TAX NO.
DO YOU EXPECT TO WITHHOLD MORE THAN $200 PER MONTH?
Yes
No
HOW MANY EMPLOYEES DOES THIS BUSINESS HAVE OR WILL HAVE?
DATE ON WHICH WAGES WERE OR WILL FIRST BE PAID
DATE
/
/
SIGNATURE SECTION
I have examined this application, and to the best of my knowledge it is true and correct.
Signature
Title
Date
Must be signed by owner, partner, managing member, or Corporate officer listed in the relationship section (15 or 16) above.
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