Business Registration Form
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1SALEM INCOME TAX DEPARTMENT
R #
231 S. Broadway Ave.
D#
Salem, OH 44460
Ph: 330-332-4241 Ext. 225
FAX: 330-337-0246
Email:
WH #
B u s i n e s s R e g i s t r a t i o n Fo r m
COMPLETE & RETURN THIS REGISTRATION BEFORE STARTING BUSINESS IN SALEM
NAME: _____________________________________________________
e-mail:
DBA: _______________________________________________________
____________________________________
BUSINESS ADDRESS: ________________________________________
Location of Project: _____________________
________________________________________
_____________________________________
MAILING ADDRESS: _______________________________________
General Contractor: _____________________
________________________________________
_____________________________________
TELEPHONE: ______________ SECOND PHONE: ________________
FEDERAL EMPLOYER ID: _________________________
SS# ________________________
(required if Sole Proprietorship)
TYPE OF BUSINESS CONDUCTED: ___________________________________________________________________
REASON FOR REGISTRATION: _____ Courtesy Withholding for Salem Resident _____ Doing Business in Salem this year
_____ Business with a Fixed Location in Salem
DATE STARTED IN SALEM: __________________
INDICATE TYPE:
Sole Proprietorship _____ C-Corp _____
Partnership _____
S-Corp _____
ACCOUNTING PERIOD:
Calendar Year _____
Trust/Estate _____
Non Profit Corp _____
Fiscal Year _____
Non Profit Corp _____ (attach 503C)
(Fiscal Year end Month ____________)
Other _____
OWNERS NAME & ADDRESS: ___________________________________________________________________________
_______________________________________________________________________________________________________
IF CORPORATE SUBSIDIARY: Indicate Parent Company, Name & Address: ______________________________________
_______________________________________________________________________________________________________
IF PARTNERSHIP, ASSOCATION OR OTHER BUSINESS VENTURE: Attach names and addresses of all owners.
DO YOU HAVE EMPLOYEES WORKING IN SALEM ?
Yes _____ No _____ (If yes, enter Federal Employee ID # above)
Will employees be working in Salem less than 12 days this year?:
Yes _____ No _____
Are Payroll Taxes Filed and Paid by a Payroll Service ?:
Yes _____ No _____
If Yes, Name of Payroll Service : _______________________________________Contact Phone _________________
DO YOU HAVE SUBCONTRACTORS WORKING IN SALEM ? Yes ___ No ___ If yes, attach list of subcontractors
(Registration is required for all subcontractors, before working in Salem, Ohio)
DO YOU MAKE RENT OR LEASE PAYMENTS IN SALEM ? Yes ____ No ____ If yes, attach name & address of landlord(s)
FOR SALEM BUSINESSES:
DO YOU RENT OR LEASE PROPERTY TO OTHERS ? Yes ____ No ____
If yes, attach name & address of tenant(s)
SIGNATURE: _______________________________________ TITLE: _________________________
DATE: _____________
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