Form Tr 1 - Application For Tire Distributor License
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TR 1
Rev. 4/08
P.O. Box 530
Columbus, OH 43216-0530
Application for Tire Distributor License
Name of business
FEIN
DBA
Social Security number
Street
Telephone number
City
State
ZIP code
Fax number
1. Mailing address if different from above
2. Business structure:
Sole owner
Partnership
Corporation
Fiduciary
Association
Other
3. Date of first taxable sale
4. Type of business:
Wholesale
Retail
Broker
Importer
If wholesale/retail, percentage of each: Wholesale
%
Retail
%
5. List on the reverse side each location covered by this application.
6. List below the titles, names and addresses of all corporate officers, association officers or partners.
Title
Name
Address
Social Security No.
Federal Privacy Act
Because we require you to provide us with a Social Security number,
sections 5703.05, 5703.057 and 5747.08 authorize us to request this
the Federal Privacy Act of 1974 requires us to inform you that providing
information. We need your Social Security number in order to administer
us with your Social Security number is mandatory. Ohio Revised Code
this tax.
I declare under penalties of perjury that the above statements have been examined by me and to the best of my knowledge
and belief are true, complete, and correct.
Signature
Title
Date
This is NOT an annual license. The license is in effect until you cease business. Mail application to the Ohio Department of
Taxation, Excise Tax Section, P.O. Box 530, Columbus, OH 43216-0530. If you have any questions regarding this applica-
tion, please call (855) 466-3921.
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