* Required

Federal Employer ID Number: (enter as 99-99999999): Social Security Number (enter as 999-99-9999): Secretary of State Entity Number: Ohio Master Number (enter as 99-99999999): *1. Type of Ownership:

*2. When did, or will you start making taxable sales (enter as mm/dd/yyyy):

*3. Provide NAICS Code:

*State nature of business activity:

4. Legal Name (Corporation, sole owner, partnership, etc.)

*5. Business, Trade or DBA Name:

*6. Primary Address:

Street (Address pf corporation, sole owner, partnership, etc.)
City
State
Zip

Business Phone Number
(enter as 999-999-9999): Fax Number
(enter as 999-999-9999): Secondary Phone Number
(enter as 999-999-9999):

7. Mailing Address (if different from Primary Address):

Street
City
State
Zip

*8. Business Address:

Street
City
State
Zip

*9. How much sales tax do you expect to collect each month?

$200 or greater Less than $200

10. Have you applied for a liquor permit transfer?

Yes No

Vendor's License Number: Liquor Permit Number:

11a. Have you applied for a new liquor permit?

Yes No

Date applied for (enter as mm/dd/yyyy):

11b. Do you intent to make non-liquor sales prior to the issuance of your new liquor permit?

Yes No

Date business will or did begin (enter as mm/dd/yyyy):

12. If you operate as a corporation, LLC, or partnership, list appropriate names, addresses, and identification numbers below:

Title
Name
Street
City
State
Zip
SSN/ITIN/FEIN

Title
Name
Street
City
State
Zip
SSN/ITIN/FEIN

Title
Name
Street
City
State
Zip
SSN/ITIN/FEIN

13. Name, phone number, fax number, and e-mail address of individual the department should contact regarding this account.

Name: Phone Number(enter as 999-999-9999): Fax Number(enter as 999-999-9999): E-mail address: