ACCT #: 
                                      Business Registration Form                                   
  City of Newark                   Check appropriate taxing authority                             Phone:      740-670-7580 
 Income Tax Division                                                                              Fax:          740-670-7581 
  PO Box 4577                  City of Newark                                     Etna Twp. JEDZ1 Email:      citytax@newarkohio.net 
 Newark Oh  43058              Etna Twp. JEDZ2                                 Pataskala JEDD     Website:   www.newarkohio.net 
                              USE A SEPARATE FORM FOR EACH AUTHORITY 
 
 Please assist us in completing your account information.  If you should have any questions while completing this 
 form, please contact our office.  Mail, fax, or email this completed form with any additional attachments within 10 
                                   business days. Thank you for your cooperation. 
                                                            
 1. Name                                                                                      Phone                                   
  
 2. Trade Name (DBA)                                                                          Fax                                     
 
 3. Federal EIN or Soc Sec  #                                                                 Email                                   
 
 4. Address                                                                                                                           
 
 5. Name and address where tax forms are to be mailed (if different from above)                                               
                                                                                                                                      
 6. Type of business ownership (check one) 
      
           Non-resident sole proprietor (Schedule C)               Non-profit organization (Go to question 7) 
           Partnership                                             Corporation 
           Other (please specify)                            
     (If sole proprietor, please provide name and residence address of owner on back.  For all other entities, please 
     list names of members, partners, or officers with their addresses, social security numbers, and titles held on 
     back.) 
 
 7. Is your company      only withholding income tax as a convenience forresident employees? 
             Yes  Date withholding started:                 (Go to signature line)        No  (Complete entire form) 
 
 8. Nature of  business conducted:                                                                                                    
 
 9. When does your fiscal year end—must be the same as your federal return (month and day)                                            
 
 10. Give date business and/or withholding began in this taxing jurisdiction                                                          
      
 11. Do you have employees working in the taxing jurisdiction at the top of the form? 
              Yes—If yes, approximate monthly withholding $    100.00                                    No 
 
 12. Will you be using subcontractors?         Yes—If yes, approximate #                                           No 
     If yes, submit a list of all subcontractors on your letterhead.  (Include: Account #                   , business name, 
     address, contact name, phone number, and nature of work being performed.) 
 
 13. If you operate more than one place of business or own rental property, please give name and/or location of each.  
     If more space needed, you may submit the listing on your letterhead and reference account #                             .  
                                                                                                                                      
Name of Contact Person (Please print)                                                                                                 
 
Contact Person Signature                                                                                    Date