AMHERST INCOME TAX DEPARTMENT 
                                                               480 Park Ave 
                                                           Amherst, OH  44001 
                                              Phone (440) 988-4212       Fax (440) 988-3749 
                                                                      
                                                 RESIDENT BUSINESS REGISTRATION  
                                                                      
Company Name:               __________________________________________                                Tax ID:  ________________________ 
DBA/Trade Name:             __________________________________________                                Date Started or Acquired in Amherst   
 
                                                                                                                                       ______/______/_______   
                                                                                                                                                             
Amherst  Address:           __________________________________________                 
                            __________________________________________                                Amherst Phone:  (       ) _______________ 
Email Address:              __________________________________________                                Amherst Fax:       (       ) _______________ 
 
Address of Main Office:     __________________________________________                                Main Office Phone: (      ) ______________ 
 
                            __________________________________________            
   
                                                      Net Profit Tax Information 
 
Mailing Address for         __________________________________________                                Accounting Period Used: 
    Net Profit Forms:       __________________________________________                                   Calendar Year    FYE, Month ____ 
                            __________________________________________ 
Tax Dept Contact Name:  __________________________________________             Phone: (       )                     __________________                       

 Type of Ownership:          Corporation    Partnership   1120S   Sole Proprietorship  Non-Profit             
                                             Other: _________________________________________ 
 
If this business is a Sole Proprietorship, Partnership or LLC, complete the following information: 
          
Name:      __________________________  SS# _________________                   Name:      __________________________  SS# ________________  
Address:  ________________________________________________                 Address:  _______________________________________________ 
 
Name:      __________________________  SS# _________________                   Name:      __________________________  SS# ________________  
Address:  ________________________________________________                 Address:  _______________________________________________ 
 
                                           Payroll Withholding Information – Tax Rate 1.5% 
                                                                      
Remittance Frequency:      Monthly (required if over $200 per month)           Quarterly            Number of Amherst Employees          _____ 
 
Mailing Address for W/H Forms:  ___________________________   Payroll Contact Name:   _____________________   
                                          ________________________________                            Phone: (       ) ________________   
                                            _________________________________                                      
    
OR:         Payroll Service (FEIN is used as the Account Number)                        
         Company Name:    ____________________________________________________ 
         Address:               ____________________________________________________    
                                ____________________________________________________ 
         Contact Name/Dept:  __________________________________________________     Phone: (       ) _______________ 
If Amherst location is rented or leased, provide the following information: 
Name:      _____________________________________      Address: _____________________________________________________________               
Phone: (       ) _______________________                       _____________________________________________________________ 
 
               Signature:  _____________________________________  Title:  _________________   Date:  _____/_____/_______