Form Pa-100 - Pa Enterprise Registration Form February 2006 printable pdf download

PA-100 (02-06)

RECEIVED DAT E

C O M M O N W E A LTH OF PENNSYLVA N I A

M A I L COMPLETED A P P L I C ATION TO :

PA ENTERPRISE

D E PARTMENT OF REVENUE

BUREAU OF BUSINESS TRUST FUND TA X E S

R E G I S T R ATION FORM

PO BOX 280901

HARRISBURG, PA 1 7 1 2 8 - 0 9 0 1

D E PARTMENT USE ONLY

D E PA RT M E N T OF REVENUE &

TYPE OR PRINT LEGIBLY, USE BLACK INK

D E PA RT M E N T OF LABOR AND INDUSTRY

SECTION 1 – REASON FOR THIS REGISTRAT I O N

REFER TO THE INSTRUCTIONS (PAGE 18) AND CHECK THE APPL ICABLE BOX(ES) TO INDICATE THE REASON(S) FOR THIS REGISTRAT I O N .

6 . DID THIS ENTERPRISE:



1 .

NEW REGISTRAT I O N



YES

N O ACQUIRE A L L OR PA RT OF ANOTHER BUSINESS?



2 .

ADDING TAX(ES) & SERV I C E ( S )



YES

N O R E S U LT FROM A CHANGE IN LEGAL STRUCTURE (FOR EXAMPLE, FROM INDIVIDUAL



3 .

R E A C T I VATING TAX(ES) & SERV I C E ( S )

P R O P R I E TOR TO CORPORATION, PA RT N E R S H I P TO CORPORATION, CORPORAT I O N



4 .

ADDING ESTABLISHMENT(S)

TO LIMITED LIABILITY C O M PA N Y, ETC)?



5 .

I N F O R M ATION UPDAT E

YES

N O UNDERGO A MERGER, CONSOLIDATION, DISSOLUTION, OR OTHER RESTRUCTURING?

SECTION 2 – ENTERPRISE INFORMAT I O N

1. D ATE OF FIRST O P E R AT I O N S

2. DATE OF FIRST O P E R ATIONS IN PA

3. ENTERPRISE FISCAL YEAR END

4 . ENTERPRISE LEGAL N A M E

5. FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)

6 . ENTERPRISE TRADE NAME (if different than legal name)

7. ENTERPRISE T ELEPHONE NUMBER

(

)

8 . ENTERPRISE STREET ADDRESS (do not use PO Box)

C I T Y / TO W N

C O U N T Y

S TAT E

Z I P CODE + 4

9 . ENTERPRISE MAILING ADDRESS (if different than street address)

C I T Y / TO W N

S TAT E

Z I P CODE + 4

1 0 . L O C ATION OF ENTERPRISE RECORDS (street address)

C I T Y / TO W N

S TAT E

Z I P CODE + 4

11. E S TA B L I S H M E N T NAME (doing business as)

12. NUMBER OF

13. PA S C H O O L D I S T R I C T

14. PA M U N I C I PA L I T Y

E S TABLISHMENTS *

* ENTERPRISES WITH ONE OR MORE ESTABLISHMENTS WITHIN PA, WHOSE PA ADDRESS WAS NOT ENTERED ABOVE, MUST COMPLETE SECTION 17.

(SEE GENERAL INSTRUCTIONS AND SECTION 17 FOR MORE INFORMATION.)

SECTION 3 – TAXES AND SERVICES

AL L REGISTRANTS MUST CHECK THE APPLICABLE BOX(ES) TO INDICATE THE TAX(ES) AND SERVICE(S) REQUESTED FOR THIS REGISTRATION AND COMPLETE THE

CORRESPONDING SECTIONS INDICATED ON PAGES 2 AND 3. IF REACTIVATING A N Y PREVIOUS ACCOUNT(S), LIST THE A C C O U N T NUMBER(S) IN THE SPACE PROVIDED.

ACCOUNT NUMBER



CIGARETTE DEALER’S LICENSE

SALES, USE, HOTEL O C C U PA N C Y

TAX LICENSE



C O R P O R ATION TA X E S



S M A L L GAMES OF CHANCE LIC./CERT.

EMPLOYER WITHHOLDING TA X



FUELS TAX PERMIT

T R A N S I E N T VENDOR CERT I F I C AT E



LIQUID FUELS TAX PERMIT

U N E M P L O Y M E N T C O M P E N S AT I O N



M O TOR CARRIERS ROAD TA X / I F TA



USE TA X



PROMOTER LICENSE



VEHICLE RENTA L TA X



PUBLIC T R A N S P O RTATION



WHOLESALER CERT I F I C AT E

A S S I S TANCE TAX LICENSE



SALES TAX EXEMPT S TAT U S

W O R K E R S ’ C O M P E N S ATION C O V E R A G E

SECTION 4 – AUTHORIZED SIGNAT U R E

I, (WE) THE UNDERSIGNED, DECLARE U NDER THE PENALTIES OF PERJURY T H AT THE STATEMENTS CONTAINED HEREIN ARE TRUE, CORRECT, AND COMPLETE.

AUTHORIZED SIGNATURE (AT TACH POWER OF AT TO R N E Y IF A P P L I C A B L E )

D AYTIME TELEPHONE NUMBER

T I T L E

(

)

TYPE OR PRINT N A M E

E - M A I L A D D R E S S

D AT E

TYPE OR PRINT P R E PARER’S NAME

T I T L E

D AYTIME TELEPHONE NUMBER

E - M A I L A D D R E S S

D AT E

(

)

Form Pa-100 - Pa Enterprise Registration Form February 2006

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