RTS-9
                                                                                                                             R. 01/13
                                                                                                                             TC
                                                                                                                             Rule 73B-10.037
                                                                                     Florida Administrative Code
                                        Florida Department of Revenue                        Effective Date 11/14

                                         Reemployment Tax*                      DOR Use Only:
                                        Application for Agent Registration      ____________________
                                                                                Agent Number

 Agent Name:                             Contact:

 Mailing Address:                        Title:

 RT Account Number (if applicable):      Phone:

 FEIN:                                   Fax:

Registering as an agent allows you to file and/or pay on behalf of the clients listed.  For the Department to 
disclose confidential tax information, a Power of Attorney (DR-835) must be submitted for each client.  You will 
not be allowed to register as an agent unless you represent at least one client.

 Client Name and Mailing Address                               RT               FEIN         *Effective 
                                                               Account No.                   Begin Date

*Effective Begin Date is the date you begin representing your client.  This date must be the beginning of a reporting period 
(i.e., 1/1/07, 4/1/07, 7/1/07, 10/1/07).

 Signature of Agent:                                                            Date:

Mail to: Account Management                                                     For more information call
         Florida Department of Revenue                                          850-488-6800.
         PO Box 6510
         Tallahassee, FL  32314-6510
* Formerly Unemployment Tax
                                         www.floridarevenue.com

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                                                                                                                             R. 01/13
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Client Name and Mailing Address                               RT                 FEIN *Effective 
                                                              Account No.             Begin Date

*Effective Begin Date is the date you begin representing your client.  This date must be the beginning of a reporting period 
(i.e., 1/1/07, 4/1/07, 7/1/07, 10/1/07).

                                        (Attach additional sheets, if necessary.)

                                        www.floridarevenue.com