APPLICATION FOR ELECTION AS A QUALIFYING CORPORATION 
            PURSUANT TO R.I.G.L. 44-3-46/44-39.3-3 
                                  
           (Must be signed by a duly authorized officer of the corporation) 
 
1. Name of Corporation _______________________________________________
 
   Address                   _______________________________________________
 
                             _______________________________________________
 
   FEI # _____________          Calendar Year _________________ 
                                          or 
                                Fiscal Year Beginning ______ and Ending ______
 
2. Number of full time equivalent active employees in Rhode Island _____________ 
   (Employee must work a minimum of thirty (30) hours per week in Rhode Island or two (2) or 
   more part-time employees must work a combined weekly hourly total of thirty (30) or more hours 
   per week in Rhode Island). 
 
3. Principal business activity: 
 
   SIC # _________________________ 
 
   Description of principal business activity: 
 
   __________________________________________________________________
 
   __________________________________________________________________
 
   __________________________________________________________________
 
Applicant must attach the names, addresses and social security numbers of all current and 
former employees who are holders of such options or who are eligible to participate in 
such plan. 
(Employee must be a Rhode Island resident who has been employed as a full-time employee at the Rhode 
Island location for at least three (3) consecutive months) 
 
This election, if approved, shall be effective as of the first day of the fiscal year for which 
the election is filed and shall be effective for that year only.  The application must be 
filed on or before the due date prescribed by law for the filing of the corporation’s tax 
return for such fiscal year. 
 
I hereby declare under penalties of perjury that the information contained in this 
application, to the best of my knowledge and belief, is true, correct and complete. 
 
DATE:  __________________        ____________________________________ 
                                 Name of Corporation
 
                                 By: ________________________________