NJ-REG-A 
(Rev 12/06) 

Business Registration and Certification for Individuals Contracting with Public Agencies 
                             and for Unincorporated Construction Contractors 

                                                                                                           OFFICIAL USE ONLY 
                                                                                                           DLN#:
Ch. 57, P.L. 2004: State law requires all contractors and subcontractors with the State or other 
public sector entities to provide proof of registration with the Department of Treasury. 

Chapter 85, P.L. 2006, defined under N.J.S.A. 54A:7-1.2: You must use this form to comply with the law if you are an 
unincorporated construction contractor performing services in NJ and need proof of registration from the Division of Revenue. 

You may use this form to comply with the above-referenced laws if you are an individual with no business tax or employer 
obligations with the State of New Jersey and are not yet registered. 

Fill out the registration section and certification below and send the completed form to: 
                                                   NJ Division of Revenue 
                                                  Client Registration Bureau 
                                                       PO Box 252 
                                                   Trenton, NJ 08646-0252 
Please note that the registrant's name listed in Section A must be the same as shown in the Certification, Section B. Type, 
machine print or hand print all information, except your signature.  If you have or will have business tax or employer 
obligations, file form NJ-REG. Call (609) 292-9292 for more information.  If you currently are registered ,please enter your  
NJ Taxpayer Identification Number in the space provided below. 

SECTION A. REGISTRATION DETAIL  
Social Security Number 
Registrant's Name 

Physical Address: 
    Street, City, State, Zip 
    Do not use P.O Box 

County
Mailing Address: 
 Street, City, State, Zip 

Contact Information: 
 Telephone Number 

E-mail Address

SECTION B. CERTIFICATION  

I __________________________________________ hereby certify that I am an individual having no business tax 
or employer obligations with the State of New Jersey. Further, I certify that any income that I derive from business activities 
with the State of New Jersey will be reported on my personal income tax return.  I understand that pursuant to State law, if I 
knowingly report inaccurate of misleading information, I maybe subject to penalties. 

Signed: ________________________________ Date: _______________ 
                  Signature 

Title:  ______________________________________________________