BOE-400-ETI (FRONT) REV. 1 (9-00)
STATE OF CALIFORNIA
APPLICATION FOR REGISTRATION — EXCISE TAXES
BOARD OF EQUALIZATION
CIGARETTE AND TOBACCO
ALCOHOLIC BEVERAGE
EMERGENCY TELEPHONE
ENERGY RESOURCES
INTEGRATED WASTE
PRODUCTS TAX LAW
TAX LAW
USERS SURCHARGE
SURCHARGE LAW
MANAGEMENT FEE
SECTION I: OWNERSHIP INFORMATION
FOR BOARD USE ONLY
1. PLEASE CHECK TYPE OF OWNERSHIP
TAX
OFFICE
NUMBER
Sole Owner
Husband/Wife
Photocopies of
HQ
Driver’s License and Social
Co-ownership
Security Card are required
General Partnership
Limited Partnership
Limited Liability Partnership
Enter Federal Employer Identification Number, (FEIN), if any
Each owner, co-owner, or partner must complete lines 2 through 9 and sign line 10.
If needed, please attach additional sheet(s) to include information for more than two partners.
OWNER OR PARTNER
CO-OWNER OR PARTNER
2. FULL NAME
(first, middle, last)
3. RESIDENCE
ADDRESS
(enter full address
including zip code)
4. TELEPHONE NO.
(
)
(
)
(residence)
5. DAYTIME
(
)
(
)
TELEPHONE NO.
6. SOCIAL
SECURITY NO.
7. DRIVER’S
LICENSE NO.,
STATE OF ISSUE,
& DATE OF BIRTH
8. PRESENT/PAST
EMPLOYER
9. NAME, ADDRESS
1.
1.
& TELEPHONE
NO. OF TWO
PERSONAL
2.
2.
REFERENCES
10. SIGNATURE
SECTION II: BUSINESS INFORMATION
1. BUSINESS OR TRADE NAME (DBA, if any)
BUSINESS TELEPHONE NUMBER
(
)
2. BUSINESS ADDRESS (do not list P.O. Box or mailing service)
CITY
STATE
ZIP CODE
3. MAILING ADDRESS (if different from No. 2 above)
CITY
STATE
ZIP CODE
4. DATE STARTED (month, day, year)
5. DAYS & HOURS
SUN.
MON.
TUE.
WED.
THURS.
FRI.
SAT.
OF OPERATION
6. ARE YOU
Starting a new business?
Making Internet sales? Website address (http)
Adding/dropping partner?
Buying a business?
Other
7. IF APPLICABLE, PLEASE INDICATE NAME OF FORMER OWNER AND ACCOUNT NUMBER
8. NAME OF BOOKKEEPER/ACCOUNTANT
ADDRESS
TELEPHONE NUMBER
(
)
9. REAL ESTATE OWNED — DESCRIPTION/ADDRESS (business/personal)
VALUE
AMOUNT OWING
(Continued on reverse)