TRI-STATE FINANCIAL GROUP, LLC                                      Tax forms and other information available at 
                   PO BOX 38                                           www.tfgtax.com 
                                                                       Phone 610-270-9520 
              BRIDGEPORT, PA 19405                                     Fax     610-270-9522 
              BUSINESS REGISTRATION/MERCANTILE LICENSE APPLICATION 
  ANSWER ALL QUESTIONS COMPLETELY. INCOMPLETE APPLICATIONS WILL NOT BE APPROVED
  A SEPARATE APPLICATION MUST BE FILED FOR EACH COMPANY DOING BUSINESS

1. BUSINESS NAME (Enter name under which business is conducted): __________________________________________________
2. COMPLETE ADDRESS OF ACTUAL BUSINESS LOCATION IN BETHLEHEM CITY (No PO Boxes, if none, write NONE):
   ___________________________________________________________________________________________________________________
3. EIN / SSN:  ________________________________________________________
4. MAILING ADDRESS (If different than above):
   _______________________________________________________________________________________________________
5. ADDRESS OF CORPORATE OFFICE:
   _______________________________________________________________________________________________________
6. PHONE NUMBERS: Local office (______)__________________________ Fax (_____)_____________________
7. DESCRIPTION OF BUSINESS ACTIVITY ___________________________________________________________________
8. DOES THIS BUSINESS HAVE OTHER LOCATIONS: (    ) Yes (    ) No   If YES , where are the other business locations:
   (    ) In Pennsylvania     (    )   Other __________________________________________________________________________
9. BUSINESS TYPE:  (    ) Sole Proprietorship  (   ) Partnership  (    ) C Corp  (    ) S Corp  (    ) LLC  (    ) Non-Profit
10. DATE STARTED IN BETHLEHEM CITY:  _________________________
11. NUMBER OF EMPLOYEES AT THIS LOCATION: (Including self-employed, partners and owners) _____________________
12. DO YOU RENT THE OFFICE SPACE OF BUILDING YOU OCCUPY? (    ) Yes  (    ) No  If YES, give name and address of
   landlord or rental agent ____________________________________________________________________________________
13. IS THIS BUSINESS A:  (    ) Retail  (    ) Wholesale  (    ) Service  (    ) Rental Income  (    ) Manufacturer
14. DO YOU OWN ANY PROPERTY IN BETHLEHEM CITY FOR WHICH YOU RECEIVE RENTAL INCOME?
   (    ) Yes (    ) No   If  YES, give name of owner or rental agent ____________________________________________________
15. ARE THERE ANY LEASED DEPARTMENTS OR CONCESSIONAIRES AT THIS LOCATION?  (    ) Yes  (    ) No
   If YES, please provide name and address of provider ____________________________________________________________
16. ARE THERE ANY SUB-CONTRACTORS PERFORMING SERVICES ON YOUR BEHALF IN CITY?  (    ) Yes  (    ) No
   If YES, please provide name and address of sub-contractor _______________________________________________________

   **All businesses and/or employers in the City of Bethlehem are required to register with the     
   Tri-State Financial Group. A Registration Fee of $25.00 must accompany this Registration Form** 

        TOTAL AMOUNT DUE WITH APPLICATION                                        $ ____25.00_____ 

   **If you have a PA HIC License you do not need to pay the $25.00 Registration Fee                               –
       Please provide following: PA HIC #: ____________________;  Expiration     ______________ ** 

                      Enclose check made payable to “CITY OF BETHLEHEM    ” –

              Mail to Tri-State Financial Group, PO Box 38, Bridgeport, PA 19405 

Print Name (Owner or Authorized Person): ________________________________________________   Date _________________ 

Signature (Owner or Authorized Person): _________________________________________________      Title  _________________