Form Cat 1 - Commercial Activity Tax Registration Page 2
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4CAT 1
Federal employer identifi cation number
Social security number
Rev. 5/11
Page 2
7. Contact information
Mailing address (if different from primary)
City
State
ZIP code
Country (if other than U.S.A.)
Offi ce/home phone number
Offi ce/home fax number
E-mail address
8. List the state
or country
under whose laws the taxpayer is organized (if applicable).
9. If you are registered with the Ohio Secretary of State, enter your charter number, registration number or
license-to-conduct-business number:
10. NAICS code:
(For most current NAICS listing, visit us at tax.ohio.gov)
11. When did you fi rst become subject to the commercial activity tax? (MM/DD/YY)
12. Do you anticipate taxable gross receipts of more than $1 million during the current calendar year?
Yes
No
I hereby declare the above to be true and correct to the best of my knowledge and belief.
Name of applicant or agent (please print)
Signature
Date (MM/DD/YY)
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