Combined Registration Application For State Of Delaware Business License And/or Withholding Agent

Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - 2000 Page 2

PART C - TO BE COMPLETED BY TAXPAYERS APPLYING FOR A LICENSE

LICENSE APPLICATIONS WILL NOT BE PROCESSED WITHOUT LICENSE FEE

LICENSE #1 - NAME AND ADDRESS

REV CODE 0101-01

Enter Federal Employer Identification Number

Social Security Number

Name

Trade Name if Different from Above

Business Location Address

Mailing Address if Different

City

State

Zip Code

City

State

Zip Code

FOR OFFICE USE ONLY

Describe your business activity

Bus Code

Suffix

When did or when will you begin operating in Delaware?

12 31

For what calendar year are you applying? Calendar year ending

[ ] Check if 65 years or older and

Proration Basis for Initial Licenses

Jan - 100%

Apr - 75%

Jul - 50%

Oct - 25%

whose total sales are less than $5,000

Multiply Annual Fee by Respective Month

Feb - 92%

May - 67%

Aug - 42%

Nov - 17%

(25% of Annual Fee)

Percentage and Circle Month Started

Mar - 83%

Jun - 58%

Sep - 33%

Dec - 8%

PLEASE READ PART C INSTRUCTIONS BEFORE COMPLETING COMPUTATION OF THE FEE.

COMPUTATION OF FEE

= $

Annual Fee

# of units if Applicable

Total License

Prorated Percentage

Total Fee

(annual fee X # of units)

LICENSE #2 - NAME AND ADDRESS

Enter Federal Employer Identification Number

Social Security Number

Name

Trade Name if Different from Above

Business Location Address

Mailing Address if Different

City

State

Zip Code

City

State

Zip Code

FOR OFFICE USE ONLY

Describe your business activity

Bus Code

Suffix

When did or when will you begin operating in Delaware?

12 31

For what calendar year are you applying? Calendar year ending

[ ] Check if 65 years or older and

Proration Basis for Initial Licenses

Jan - 100%

Apr - 75%

Jul - 50%

Oct - 25%

whose total sales are less than $5,000

Multiply Annual Fee by Respective Month

Feb - 92%

May - 67%

Aug - 42%

Nov - 17%

(25% of Annual Fee)

Percentage and Circle Month Started

Mar - 83%

Jun - 58%

Sep - 33%

Dec - 8%

PLEASE READ PART C INSTRUCTIONS BEFORE COMPLETING COMPUTATION OF THE FEE.

COMPUTATION OF FEE

= $

Annual Fee

# of units if Applicable

Total License

Prorated Percentage

Total Fee

(annual fee X # of units)

AMOUNT DUE MUST BE REMITTED WITH THIS APPLICATION. (Total Fee from License # 1 and License # 2.)

SIGNATURE

TITLE

DATE

I declare under penalties as provided by law that the information on this application is true, correct and complete.

Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - 2000 Page 2

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