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City of Brunswick, Ohio
Income Tax Department, 4095 Center Rd, Brunswick, OH 44212
(330) 558-6815 Fax: (330) 273-8023
Business Registration
Company Name: __________________________________________ Phone #: ________________________________
DBA: ___________________________________________________ Fax #: ___________________________________
Federal Identification #: _______________________________ Or Owner’s Social Security # ______________________
*** THE FEDERAL ID # IS ALSO USED AS THE ACCOUNT # ***
Local Business or job-site address _____________________________________________________________________
Mailing address, if different from above _________________________________________________________________
Initial date of business in Brunswick ___________________________ Number of Employees in Brunswick____________
Nature of business: _________________________________________________________________________________
Landlord’s name, address, and phone number, if renting building space: _______________________________________
_________________________________________________________________________________________________
Type of account needed: Net Profit Only Net Profit & Withholding Withholding Only Courtesy Only (Residence)
Check Business Type Corporation Partnership Sole Proprietor S-Corporation Non-Profit Corp
Estate or Trust Other (please define) ____________________________________________________________
For Corporation, Partnership Entities, or Sole Proprietors; list full name(s), address(es), social security #’s, and phone
#’s of each owner, Officer and/or partner (Use back if additional space is needed)
1)_______________________________________________________________________________________________
2)_______________________________________________________________________________________________
3)_______________________________________________________________________________________________
Will you be using Sub-Contractors? Yes No *If Yes: List the Name and Address of any Sub-Contractors that
you will use on the back.
(If not currently known, you must notify the City of Brunswick upon hire with the required information)
Accounting period: Calendar Year _____ Fiscal Year _____ Month Ending _____
Payroll Information
Will you be withholding employment taxes? Yes No
Date withholding will begin? __________________________________________________________________________
Do you currently use an outside payroll service? Yes No
If yes, please provide name of the payroll service _________________________________________________________
Do you lease employees from an employment agency? Yes No
Will the withholding be more than $200 per month? Yes No
Will you be withholding as a courtesy for a Brunswick resident? Yes No
If courtesy withholding, please give Name, Address, and SS# of Brunswick resident: _____________________________
________________________________________________________________________________________________
Signed: ___________________________________________________ Date: ___________________________
Print Name and Title: ______________________________________________________________________________
