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                                    CITY OF DUBLIN BUSINESS REGISTRATION 
 
The information requested on this form is essential to the establishment of your account and will be held in strictest confidence.  Please 
complete and return this form to the City of Dublin Division of Taxation.  The form can be mailed to P.O. Box 9062, Dublin OH 43017-0962.  
You may also fax it to 614-410-4956 or email it to taxinfo@dublin.oh.us.  If you have any questions, contact our office at 614-410-4460. 
 
                                                                                 Today’s Date:  ______________________________ 
                                                                                                                                                     
Business Name                                                                            Federal EIN                                                 
 
DBA:                                                                                                                                                  
 
Mailing Address                                                         City                                   State        Zip                      
 
CONTACT PERSON FOR ACCOUNT:                                                                                                                          
 
Phone                                      FAX                                     Email                                                             

                LOCATION OF BUSINESS WITHIN THE CITY OF DUBLIN (REQUIRED) 
  Check here if setting up account ONLY for employees working from home in the Dublin taxing jurisdiction (confirm addresses 
on Dublin Address Checker available on our website, www.dublintax.com).  If you only have employees working from home; the 
location of business in Dublin address is not required but you MUST attach a spreadsheet with employee names & addresses.                

Date Operations began in Dublin                                                                               # of Employees in Dublin               
Dublin Address                                                          City                                   State        Zip                      
Local Phone                                Local FAX                               Local Email                                                       
 
                                                           WITHHOLDING 
PLEASE CHECK THE APPROPRIATE BOX:                                                             Federal EIN                                            
  Employees work within the city limits of Dublin - the withholding rate is 2.0%. 
  Business performs no work in the City of Dublin.  We will be withholding additional taxes from residents as a courtesy (up to 2.0% rate). 
  Account set-up is based on business activity ONLY.  No employees physically work in the City of Dublin.   
Are you using a payroll service*?    Yes    No   Name of Payroll Service:                                                                              
Payroll Contact Name                                                                Contact phone number                                             
*If your payroll provider requires verification of your Dublin account number, fax them a copy of this form to verify that Dublin uses your 
Federal EIN as your account number. 
PLEASE INDICATE THE FREQUENCY OF WITHHOLDING:    
   Quarterly (under $200.00/month)                          Monthly (over $200.00/month)                        Semi-Monthly (over $1000.00/ month) 
                                                                                                                                                     
TYPE OF ORGANIZATION (Please check one):                                                 
Federal Form Filing Type:   Corporation (1120)             S-Corporation (1120S)  Partnership (1065)           Non-Profit   Sole Proprietor (C)  
 
                                    NET PROFIT (Corp, S-Corp, Partnership) 
 
Nature of Business                                                                       NAICS Code                                                    
The company will be filing a consolidated return as                                                            EIN                                   
List Corporate Officers and/or Owners name and Social Security Numbers: (Attach an additional list if necessary)  
Name                                                                                                           SSN                                   
Mailing Address                                                         City                                   State        Zip                      
 
                                          SOLE PROPRIETOR (Schedule C) 
 
Sole Proprietor Name:                                                                     SSN