Form 2643t - Transient Employer Tax Registration Application - 2012
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MISSOURI DEPARTMENT OF REVENUE
DLN (DOR USE ONLY)
FORM
TRANSIENTEMPLOYERTAX
Reset ALL PAGES of Form
2643T
REGISTRATIONAPPLICATION
P.O. BOX 357, JEFFERSON CITY, MO 65105-0357
Print ALL PAGES of Form
(REV 07-2012)
(573) 751-5860 Fax: (573) 522-1722
E-mail: businesstaxregister@dor.mo.gov
If you will be making sales in Missouri, you must fill out form 2643, Missouri Tax Registration Application.
BEFORETHEDEPARTMENTCANPROCESSYOURTRANSIENTEMPLOYERAPPLICATION,YOUMUSTPROVIDETHE
FOLLOWINGWITHTHISAPPLICATION:
CHECKLIST
A completed insurance certification document indicating Missouri as a covered state for Workers’ Compensation
If hiring a Missouri resident, you will need your Missouri Employment Security Account Number issued by the Missouri Department of
Labor (573) 751-3215
Your Missouri Certificate of Authority Number issued by the corporate division of the Missouri Secretary of State’s Office (866) 223-6535
A Transient Employer Bond not less than $5,000, not more than $25,000
ANSWERALLQUESTIONSCOMPLETELY.INCOMPLETEANDUNSIGNEDAPPLICATIONSWILLDELAYPROCESSING.
Reset Section 1 through 5
Ifyouhaveeverbeenissuedataxidentificationnumber,enterthatnumberinlines1and2ifapplicable:
1. Missouri Tax ID Number issued by the Missouri Department of
2. Federal ID Number (FEIN) issued by the Internal Revenue Service. To
Revenue
obtain contact IRS at (1-800-829-4933) or
____ ____ ____ ____ ____ ____ ____ ____ ____
____ ____ ____ ____ ____ ____ ____ ____
3 .Missouri Employment Security Account number, if hiring a Missouri resident: (first seven digits required)
__________________________________________
4. Checkalltaxtypesforwhichyouareapplying:
5. Describe the business activity, stating the major products sold and/or
services provided.
___________________________________________________________________
Transient Employer Withholding Tax (Bond Required)
___________________________________________________________________
Corporate Income Tax
REASONFORAPPLYING
Corporate Franchise Tax
Consumer’s Use Tax (Use tax is imposed on the storage, use, or con-
New Business
Purchase of Existing Business
sumption of tangible personal property in this state. You must pay consumer’s
Reinstating Old Business
use tax on tangible personal property stored, used, or consumed in Missouri
Converted
(must have converted through MO Secretary of State office)
unless you paid sales or use tax to the seller or the property is exempt from
Other: __________________________________________________
tax.)
___________________________________________________________
________________________________________________________
Reset Section 6 through 8
BUSINESSNAMEANDPHYSICALLOCATION
6. BusinessName(attachlistifnecessaryforadditionallocations)
Street, Highway (DonotuseP.O.BoxNumberorRuralRouteNumber)
City, State, Zip Code
County
Business Telephone Number
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
7.
The location of your job site(s) in Missouri (Attach list if necessary): _________________________________________________________________
8a.
Is this business inside the city limits of any city or municipality in Missouri? To verify go to https://dors.mo.gov/tax/strgis/index.jsp.
No
Yes—Specify the city: ________________________________________________________________________________________
8b. Is this business inside a district(s)? For example, ambulance, fire, tourism, community or transportation development.
No
Yes—Specify the district name(s): ________________________________________________________________________________
Reset Section 9
OWNERNAMEANDADDRESS
9. OwnerName(Enterlegalentitynameunlesssoleproprietor.Partners,members,andofficersmustbelistedbelow.)
If the owner is a sole owner or a partnership, you must provide:
Social Security Number
Date of Birth
Telephone Number
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ /___ ___ /___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Address
E-Mail Address
City
State
Zip Code
County
DOR-2643T (07-2012)
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