City of Mentor
Municipal Income Tax Contractor Registration Form
DATE BUSINESS ESTABLISHED:__________________FEDERAL ID NUMBER:__________________
FIRM NAME:________________________________________________________________________
TYPE OF FIRM: CORPORATION
PARTNERSHIP
SOLE PROPRIETORSHIP
OTHER
CORPORATION:
CORPORATION PRESIDENT’S NAME:____________________________________________________
ADDRESSPHONESOCIAL SECURITY NUMBER:
____________________________________________________________________________________
CORPORATION VICE PRESIDENT’S NAME:_______________________________________________
ADDRESSPHONESOCIAL SECURITY NUMBER:
___________________________________________________________________________________
PARTNERSHIP:
IS THE PARTNERSHIP FILING AS AN ENTITY: YES
NO
IF PARTNERSHIP IS NOT FILING AS AN ENTITY, COMPLETE THE FOLLOWING INFORMATION:
NAME ADDRESSSOCIAL SECURITY NUMBER:____________________________________________
NAMEADDRESSSOCIAL SECURITY NUMBER:____________________________________________
NAMEADDRESSSOCIAL SECURITY NUMBER:____________________________________________
SOLE PROPRIETORSHIP:
NAME OF PROPRIETOR:_______________________________________________________________
ADDRESSPHONESOCIAL SECURITY NUMBER:
____________________________________________________________________________________
OTHER:
NAME:_______________________________________TYPE:__________________________________
ADDRESSPHONESOCIAL SECURITY NUMBER:
____________________________________________________________________________________
DOES FIRM HAVE EMPLOYEES?
YES
NO
IF YES HOW MANY?_______________
FIRM USING SUB-CONTRACTORS? YES
NO
IF YES SUBMIT A SEPARATE LIST OF
EACH SUB-CONTRACTOR LISTING NAME/ADDRESS/SOCIAL SECURITY NUMBER
DATE STARTED ON PROJECT:_________________________EXPECTED COMPLETION DATE:_____________
CITY PROJECT NUMBER:_____________________________FISCAL YEAR END_________________________
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