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 # ______________________ 
  
 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) 
                                *** THE FEDERAL ID # IS ALSO USED AS THE ACCOUNT # *** 
                                                        
                                             Check Business Type 
                                                        
 Sole Proprietor    CorporationPartnershipS-CorporationNon-Profit Corp Estate or Trust  
Other (please define) ________________________            
 
For Corporation, Partnership Entities, or Sole Proprietors; list full name(s), addresses(es), social security #’s, and 
phone #’s of each owner, Officer and/or partner (Use back if additional space is needed) 
 
1)_______________________________________________________________________________________________ 
 
2)_______________________________________________________________________________________________ 
 
3)_______________________________________________________________________________________________ 
 
*List the name and address of any sub-contractors that you will use on the back. 
 
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: _______________________________________________________________________________