* Required

Federal Employer ID Number (enter as 99-99999999): Social Security Number (enter as 999-99-9999): Ohio Charter Number: Ohio Certificate 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: *5. Business, Trade or DBA Name: *6. Home Office Address:

Home Office Phone (enter as 999-999-9999): Home Office Fax (enter as 999-999-9999):

*7. Business Address:

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

8. Mailing Address: *9. How much sales tax do you expect to collect each month?:

$200 or greater Less than $200

10. Previous Owner's Name & Address:

Previous Vendor's Number:

11. Will you be selling beer, wine or liquor at this location?:

Yes No

If yes, list your Liquor Control Permit Class: If yes, list your Liquor Control Permit Number: Employer Withholding Number (enter as 99-99999999):

12. Do you intend to make non-liquor sales prior to the issuance of your permit?:

Yes No

13. If you operate as a corporation or partnership, list appropriate names, addresses and social security numbers below.

President/Partner Name & Address: President/Partner Social Security Number (enter as 999-99-9999): Vice President/Partner Name & Address: Vice President/Partner Social Security Number (enter as 999-99-9999): Treasurer/Partner Name & Address: Treasurer/Partner Social Security Number (enter as 999-99-9999): Secretary/Partner Name & Address: Secretary/Partner Social Security Number (enter as 999-99-9999):