KENAI PENINSULA BOROUGH 
                                           APPLICATION FOR CERTIFICATE OF REGISTRATION 
                                                                TO COLLECT SALES TAX 
                                                         144 N. Binkley Soldotna, Alaska 99669-7599 
                                                                       Phone (907) 714-2175 
                                                                       Web Site: www.kpb.us 
                                                                       Email: salestax(til,kp  b.us 
                                                                                                                      Account#: 
                                                                                                                    I                  I  I  I  I  I  I  I 
SECTION 1.  ENTITY TYPE: Please select ONE box (Note:  Failure to provide the proper documents could delay registration.) 
      Individual/Sole Proprietor                         Partnership                                               Limited Liability Company (LLC) 
                                                                                                                   LLC State Documents Required 
      Corporation                                        Non-Profit                                               Church or Religious Organization: IRS 501(C) or 
      Corporation State Documents Required               Non-Profit IRS 501(C) Documents Required                  Non-Profit Certificate from the State of Alaska 
SECTION 2.  BUSINESS INFORMATION 
Business Name (Doing or Conducting Business As, Individual, Company)                                          Date Opened On The Peninsula 

Additional OBA/Name Used (Corporate name, LLC, Parent Company, Etc.):                                       I

Business Address-Street No.          N,E,S,W      Street Name                                                                                Ste/Apt# 
(NO PO Boxes) 
City                             I                State                     Zip + 4                                   Country              I

Mailing Address                      N, , ,
                                       E S W      Street Name                                                       I                        Ste/Apt# 

City                             I                State                     Zip + 4                                   Country              I

Business  mail Address 
         E                                                                  Area Code          Business Phone       I      Area Code         Business Fax 

Business Parcel #                            Alaska  tate Business License # 
                                                   S                              NAICSCodeI                             I   Federal Tax I.DI# 
                                           I                                                                                I
Briefly Describe Business Conducted: 

Do you own your       Yes        No    If yes, is this your residence?      Yes    No   If No, complete the following Landlord/Property Manager Information: 
business location? I I I                                               I               I
Landlord/Property Manager Name                       Address                      N, , ,E S W   Street Name                                  Ste/Apt# 

City 
                                           S tate  I     Zip+4                                ICountry                       Area Code     IPhone No. 
                                                         I                                    I                            I
Method used in submitting                                Is this a seasonal                      If yes, business            Month                        Month 
Sales Tax Returns:          I    Cash        Accrual Ibusiness?             I Yes  I NoI         conducted from:      I                      To    I
SECTION 3.  PERSON RESPONSIBLE FOR FILING OR AGENT FOR SERVICES OF PROCESS 
Person Responsible For Filing Returns                                         Title/Company                                    Area Code     Contact Phone 
                                                                                                                                           I
Mailing Address                                                               City                                             State                   Zip+4 

                                                                                                                                                      I
SECTION 4.  PREVIOUS TAX REGISTRATION 
Previous Sales Tax Registration Number       Former Business Name                                                              Date of New Ownership 

Previous Owner Name                          I                                Previous Owner Mailing Address, City, State, Zip 

SECTION 5.  BUSINESS REFERENCE 
   Name                                                                                                            (Area Code) Phone No. 
I.                                                                                                                I
   Address                                                                      City                                         State           Zip+4 
                                                                                I                                          I                I
   Name                                                                                                            (Area Code) Phone No. 
2.                                                                                                                I
   Address                                                                      City                               State             Zip+4 
                                                                                I                                                    I                    I 

SECTION 6.  OWNER INFORMATION 
I Name - Last, First, Middle Initial                                  Title                                Date of Birth 
                                                                                                         I 
  Mailing Address                                                     Social Security # 

  City                                        State     Zip+4 Country                              (Area Code) Phone No. 

  Registration No. &DBi\ of other businesses owned:I    I     I                                   I

2 Name, - Last, First, Middle Initial                                 Title                                Date of Birth 

  Mailing Address                                                     Social Security #                  I

  City                                        State     Zip+4 Country                              (Area Code) Phone No. 

  Registration No. &DBi\ of other businesses owned:I    I     I                                   I

3 Name - Last, First, Middle Initial                                  Title                                Date of Birth 

  Mailing Address                                                     Social Security #                  I

  City                                        State     Zip+4 Country                              (Area Code) Phone No. 

  Registration No. &DBi\  of other businesses owned:I   I     I                                  I

4 Name - Last, First, Middle Initial                                  Title                                Date of Birth 

  Mailing Address                                                     Social Security #                  I

  City                                        State     Zip+4 Country                              (Area Code) Phone No. 

  Registration No. & DBi\ of other businesses owned:I   I     I                                   I

SECTION 7.  SIGNATURE AND DISCLOSURE 

NOTE: A PURCHASE/SUCCESSOR OF AN ONGOING BUSINESS MAY BE HELD LIABLE FOR UNPAID SALES TAX 
       OBLIGATIONS OF THE PREVIOUS OWNER OF THE ASSUMED BUSINESS.  (KPB 5.18.130 (B)) 

I/WE ARE A WARE THAT THE BOROUGH MUST BE NOTIFIED IN WRITING OF ANY CHANGE IN ADDRESS, OWNERSHIP, 
FILING STATUS, CLOSURES OF BUSINESS, OR ANY CORRECTIONS IN GENERAL TO THIS RECORD. 

I DECLARE, UNDER PENALTY OF PERJURY, THAT THIS APPLICATION IS TRUE AND COMPLETE.  I ACCEPT THE 
LICENSE  AUTHORIZED  AND  ISSUED  IN  RESPONSE  TO  THIS  APPLICATION  WITH  THE  CONDITION  THAT  I 
REPORT TIMELY AND PAY ANY AND ALL TAXES DUE BY ME TO THE KENAI PENINSULA BOROUGH. 

Partnerships require the signatures of ALL Partners listed on this application. Limited Liability Companies, Corporations, and Sole 
Proprietors require the signature of at least one owner, officer, or member of the organization. 

Print Name                                    Signature         Title                                                Date 

Print Name                                    Signature         Title                                                Date 

Print Name                                    Signature         Title                                                Date 

Print Name                                    Signature         Title                                                Date