Form Ar-1r - Combined Business Tax Registration Form Page 2

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SECTION C - RESPONSIBLE PARTY

. Complete this line for each responsible party who is an owner, partner, member, corporation officer or trustee.

. Attach additional pages if needed.

. In the case of limited partnerships, complete this section for each general partner.

. See instructions for additional information.

a) Name of Responsible Party

b) SSN or FEIN

c) Title

d) Effective Date

e) Phone Number (Include Area Code)

f) E-Mail Address

g) Street Address or PO Box

h) City, State, Zip Code

a) Name of Responsible Party

b) SSN or FEIN

c) Title

d) Effective Date

e) Phone Number (Include Area Code)

f) E-Mail Address

g) Street Address or PO Box

h) City, State, Zip Code

a) Name of Responsible Party

b) SSN or FEIN

c) Title

d) Effective Date

e) Phone Number (Include Area Code)

f) E-Mail Address

10.

g) Street Address or PO Box

h) City, Sate, Zip Code

a) Name of Responsible Party

b) SSN or FEIN

c) Title

d) Effective Date

e) Phone Number (Include Area Code)

f) E-Mail Address

11.

g) Street Address or PO Box

h) City, State, Zip Code

Contact Information

a) Name

b) Title

c) Contact Phone Number: (including area code)

12.

d) E-Mail Address

e) Fax Number

SECTION D - SIGNATURE

Important - Read Before Signing.

This registration form must be signed by a responsible party who is authorized to sign on behalf of the organization. The Proprietor must sign for sole

proprietorship.

I declare under the penalties of perjury that the information provided (including any accompanying statements) has been examined by me, and to the

best of my knowledge and belief, is true, correct, and complete.

13.

a) Signature

b) Date

c) Printed Name

d) Title

Revised 08/10/2012

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