11/17
                                                                                  IT 1
                                                                                  Application for Registration 
                     P.O. Box 182215                      07100100
                     Columbus, OH 43218-2215                                      as an Ohio Withholding Agent
                     (888) 405-4089
                                                  Reset Form

EI                         Number    Secretary of State Entity Number

Check here to reactivate an account          Provide account number to reactivate.

1. Checktypeofownership:      Soleowner           Partnership     Corporation     Nonprofit LLC       LLP       LTD 
        Singlemember    Other        (pleasespecify)

2.                          (MM/DD/YY)
                                                                                        (Forthemostcurrentlisting,search
3. Provide NAICS code and state nature of business activity                           NAICS on our website at tax.ohio.gov)

4. Legalnameofbusiness
5. TradenameorDBA
6. Primary address of business
                              Street                                                        State             ZIPcode

                     e number                     Fax number                                Secondary phone number
7. Mailingaddress
                 Street                                                                                       ZIPcode
8. Check the box applicable to your estimated employer withholding remittance amount per year:
        $2,000orless                 Greaterthan$2,000,butlessthan$84,000             Atleast$84,000

9. InformationforindividualresponsibleforfilingreturnsandmakingpaymentofOhioandschooldistrictwithholdingtaxes:

                                             T                       number                       SSN/ITIN

        Street                                                                          State            ZIPcode
10. Name, phonenumber,faxnumberande-mailaddressofindividualthedepartmentshouldcontactregardingthisaccount

   Name                                      Phone number            number                 E-mailaddress

                                             Federal Privacy Act Notice
               Because we require youto provide us with a Social Security number, the Federal Privacy 
               Act of 1974 requiresustoinformyouthatprovidinguswithyourSocialSecuritynumberis
               mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize us to
               requestthisinformation.WeneedyourSocialSecuritynumberinordertoadministerthistax.