Form Dr-1sn - Registration Application For Secondhand Dealers And Secondary Metals Recyclers Page 3
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1
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5Registration Application for Secondhand Dealers
DR-1S
R. 01/17
and Secondary Metals Recyclers
TC
Rule 12A-17.005
Florida Administrative Code
Effective 01/17
Business Partner Number - This number is located on the
Business Identification Number - Provide the Federal Employer
back of your sales and use tax Certificate of Registration
Identification Number (FEIN) of the business or Social Security
(Form DR-11).
Number (SSN) * of the business owner.
Business Partner Number
FEIN
SSN*
*
Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida’s taxes. SSNs
obtained for tax administration purposes are confidential under ss. 213.053 and 119.071, F.S., and not subject to disclosure as public records.
Collection of your SSN is authorized under state and federal law. Visit our Internet site at: and select “Privacy Notice” for more
information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.
Business Structure and Ownership (check one):
Sole Proprietorship
Partnership
Corporation
Limited Liability Company
Document number issued by the Florida Secretary of State when the entity was
chartered or authorized to conduct business in Florida:
Date of Florida incorporation, formation, organization or date of authorization to
conduct business in Florida:
Legal name of business entity (individual owner, corporation, limited liability company, or partnership):
Trade, Fictitious, or “doing business as” name (if different than above):
Mailing address ______________________________________________________________________________________________________
City _____________________________________ State ________________________________ ZIP _________________________________
Telephone Number: ( _____ ) ______________________________ Email Address: _______________________________________________
Your email address is treated as confidential information (section 213.053, F.S.), and is not subject to disclousure of public records
(section 119.071, F.S.).
Ownership Information: Provide the full name, title, SSN, address and telephone number of each business owner, officer, member,
director, partner, and stockholder with a controlling interest. Make copies of this page if additional space is needed.
Name
Street address
City/State/ZIP or
SSN
Telephone number
Title
Postal Code/Foreign Country
( _ _ _ ) _ _ _ - _ _ _ _
__ __ __- __ __ - __ __ __ __
( _ _ _ ) _ _ _ - _ _ _ _
__ __ __ -__ __ - __ __ __ __
( _ _ _ ) _ _ _ - _ _ _ _
__ __ _ - __ __ - __ __ __ __
( _ _ _ ) _ _ _ - _ _ _ _
__ __ - __ __ - __ __ __ __
For DOR Office Use Only
h
Approved
Denied
By: (User ID) ___________________ Date: _________________________
h
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