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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 it to the City of Dublin Taxation, P.O. Box 9062, Dublin OH 43017-0962 within 10 days.  If you have any questions, 
please contact the City of Dublin Taxation at 614-410-4431.  If you would prefer to fax the form do so at 614-448-9454.  The form can also be 
emailed to taxinfo@dublin.oh.us. 
                                               NET PROFIT 
 
Type of Organization (Please check one)                                             Date ______________________________ 
 Corporation   S-Corporation   Partnership   Non-Profit   Sole Proprietor    Other (Please explain)___________________________ 
COMPANY NAME______________________________________________________EIN # ___________________________________________ 
                                                                                    (DUBLIN ACCOUNT NUMBER) 
DBA ___________________________________________________________________________________________________________________ 
Street Address  __________________________________________________  City ______________________  State ______  Zip  ____________ 
Phone Number   ___________________________  Fax  _______________________  Email  ___________________________________________ 
NAICS Code ______________  (1120 Schedule K line 2A; 1120S Box B; 1065 Box C)  Type of Business   _______________________________ 
 If a Limited Liability Company (LLC) will the Partnership or Partners file? ______________________________________________________ 
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  _________________________________ 
Street Address  ___________________________________________  City ___________________  State ________  Zip  ____________________ 
LOCATION OF BUSINESS IN THE CITY OF DUBLIN (Mandatory) :   
Street Address   __________________________________________________________  City  ___________  State  _____  Zip  ______________ 
Local Phone #  ______________________  Local Fax #  ______________________    Email ___________________________________________ 
Date Operations began in Dublin _____________________________________      Number of Employees  _______________________________ 
 
                                               SOLE PROPRIETOR 
If you are a Sole Proprietor and also do not have employees, please complete the following only.  If you have employees complete the 
withholding portion of this form. 
 
NAME   _______________________________________________________________________________  SSN# ___________________________ 
Street Address  ______________________________________________  City  ____________________ State:  _______ Zip:  ________________ 
Phone Number   _______________________  Fax   ______________________  Email   ______________________________ 
                                               WITHHOLDING: 
PLEASE CHECK THE APPROPRIATE BOX:                                                   EIN # ______________________________ 
                                                                                                (DUBLIN ACCOUNT NUMBER) 
  Employees work within the city limits of Dublin  - the withholding rate is 2%. 
  Business performs no work in the City of Dublin.  We will be withholding taxes from residents as a courtesy. 
  NO EMPLOYEES work  in the City of Dublin. 
Are you using a payroll service ?    Yes    No   Name of Payroll Service:  _______________________________________________________   
Contact Name  __________________________________________  Contact phone number___________________________________________     
 
PLEASE INDICATE THE FREQUENCY OF WITHHOLDING:    
  Quarterly (under $200.00/month)                          Monthly (over $200.00/month)                         Semi-Monthly (over $1000.00/ month) 
 
IF YOUR PAYROLL PROVIDER REQUIRES VERIFICATION OF YOUR DUBLIN ACCOUNT NUMBER, FAX THEM A COPY OF 
THIS FORM TO VERIFY DUBLIN USES YOUR EIN AS OUR ACCOUNT NUMBER. 
 
CONTACT PERSON FOR ACCOUNT:  __________________________________________  Phone #  ________________________________ 
 
ALL FORMS ARE AVAILABLE ON OUR WEB SITE: www.dublintax.com Dublin is not a pure zip code please call for verification of 
address if you are not sure of the location. 

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