Income Tax Division 
                                                                     100 Lockville Road • Pickerington, Ohio 43147 
                                                                     P: (614) 837 4116 • F: (614) 833-       -2201 
                                                                                         www.pickerington.net                                                 
 
                                    BUSINESS ACCOUNT APPLICATION 
            (MANDATORY REGISTRATION ACCORDING TO ORDINANCE SECTION 880.43) 
 
FEIN/SSN: __________________ Business Name: ____________________________________________________              
 
Mailing Address: _______________________________________________________________________________               
 
Home Office Address: ___________________________________________________________________________               
(if different from mailing address) 
 
Business Location: ______________________________________________________________________________              
 
Business Type     :  Sole Proprietorship         Corporation         Partnership         Other: ________________ 
 
Nature of Business: _____________________________________________________________________________              
 
Pickerington Start Date: ________________ Phone: __________________ Home Office Phone: ________________          
 
   Calendar Year     Fiscal Year Ending ______________  
 
Please check items that apply: 
 
NET PROFIT 
 
   Business Located in Pickerington 
 
   Business Conducted within Pickerington 
 
WITHHOLDING 
  
   Pickerington Courtesy Withholding (resident is working in and paying tax to another city)  rate is 0.5%–  
 
   Employee’s address: ______________________________________________________________ 
 
   Pickerington Withholding for Employees Working in Pickerington  rate is 1.0%–  
 
   Subcontractor  rate is 1.0% –    (If you will be subcontracting work in the City, you must attach a list of names, mailing addresses, and nature of work.) 
 
Respondent’s Signature: _____________________________________ 
 
Printed Name: ______________________________________ Title: ______________________________________                                                                                  

If you would like your account number immediately, please provide your email address or phone number below: 
  
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