Contractor/subcontractor/1099 Employee Registration Form Page 2
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C I T Y O F S A L E M
Contractor/Subcontractor/1099 Employee Registration Form
Codified Ordinances Chapter 181 & 1145
YOU MUST COMPLETE THE 5 STEPS BELOW TO APPLY OR RENEW THE ANNUAL
YOU MUST COMPLETE THE 5 STEPS BELOW TO APPLY OR RENEW THE ANNUAL
YOU MUST COMPLETE THE 5 STEPS BELOW TO APPLY OR RENEW THE ANNUAL
CONTRACTOR REGISTRATION. TO RENEW, YOU MUST BE CURRENT WITH THE
CONTRACTOR REGISTRATION. TO RENEW, YOU MUST BE CURRENT WITH THE
CONTRACTOR REGISTRATION. TO RENEW, YOU MUST BE CURRENT WITH THE
SALEM INCOME TAX DEPARTMENT. RENEWALS & NEW APPLICANTS MUST
SALEM INCOME TAX DEPARTMENT. RENEWALS & NEW APPLICANTS MUST
SALEM INCOME TAX DEPARTMENT. RENEWALS & NEW APPLICANTS MUST
SUBMIT AN INSURANCE CERTIFICATE AND WORKERS COMP. CERTIFICATE.
SUBMIT AN INSURANCE CERTIFICATE AND WORKERS COMP. CERTIFICATE.
SUBMIT AN INSURANCE CERTIFICATE AND WORKERS COMP. CERTIFICATE.
YEAR FILING
P R I N T
A L L
I N F O R M A T I O N
1
__________________
YOUR STATE OF OHIO CONTRACTOR LICENSE NUMBER:
Date:
TYPE OF CONTRACTOR: (General/Plumbing/Electrical, etc.) ____________________________________________________
List the address location where you are working: ______________________________________________________________
E-mail ADDRESS: ______________________________________________________________________________________
NAME of Business Owner: _______________________________________________________________________________
Doing Business As (Business Name): _______________________________________________________________________
ADDRESS: ___________________________________________________________________________________________
CITY: _____________________________ STATE: ________ ZIP: __________ PHONE: ____________________ EXT:_____
2
COMPLETE THE ENCLOSED INCOME TAX BUSINESS FORM. IN ADDITION TO THIS FORM, EXISTING BUSINESSES
WITH INCOME TAX ACCOUNTS MUST BE CURRENT TO RECEIVE A CONTRACTOR REGISTRATION NUMBER.
3
COMPREHENSIVE GENERAL LIABILITY INSURANCE:
MINIMUM REQUIRED: $300,000.00 (THREE HUNDRED THOUSAND DOLLARS) EACH OCCURRENCE COMBINED SIN-
GLE LIMIT FOR BODILY INJURY AND PROPERTY DAMAGE LIABILITY…..MUST BE CURRENT FOR THE ENTIRE PE-
RIOD OF THIS REGISTRATION…..YOU MUST ATTACH A COPY OF YOUR CERTIFICATE WITH THE CITY OF SALEM
LISTED AS A CERTIFICATE HOLDER.
YOUR INSURANCE AGENCY: ______________________________________ PHONE: _____________________ EXT:_____
4
DO YOU PARTICIPATE IN THE OHIO WORKER’S COMPENSATION PROGRAM:
YES
NO
IF YES, YOU MUST ATTACH A COPY OF YOUR CURRENT CERTIFICATE.
5
CONTRACTOR REGISTRATION
if mailing:
FEE:
MAKE CHECK PAYABLE TO:
City of Salem Zoning Office
mail this form & Income Tax form &
$50.00
CITY OF SALEM
231 S. Broadway Ave.
Ins. Cert & Comp Cert.. & check to:
Salem, OH 44460
_____________________________________________
Signature
Print Name ____________________________________________
NEW
F O R O F F I C E U S E O N L Y
CHECK NUMBER
WA
SUBS
1099
NOTES:
RENEWAL
CR
#
TELEPHONE: 330-332-4241...EXT 228
FAX: 330-332-1767
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