0 0 0 1 1 1 1 0 
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 
1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 51 
      0 0 0  4 4 4 4 0                                                                                                                           Department Use Only
      0 0 0  5 5 5 5 0                    Form                                                                                                   (MM/DD/YY)
      0 0 0  6 6 6 6 0                                  Missouri Tax Registration Application
                                         2643A
      0 0 0  7 7 7 7 0 
      0 0 0  8 8 8 8 0 
      0 0 0  9 9 9 9 0 
      1 1 1  0  0  0  0  1 Missouri Tax I.D.  
                           Number                                                                                                 Federal Employer
      1 1 1  1 1 1 1 1     (Optional)                                                                                             I.D. Number
      1 1 1  2 2 2 2 1                                          Answer all questions completely.  Incomplete and unsigned applications will delay processing.                                        .
      1 1 1  3 3 3 3 1 
      1 1 1  4 4 4 4 1                   3.  Select all tax types for which you are applying:                                                                                         r  New MO Registration
                                         Sales from a Missouri business location                                 Missouri Employer Withholding Tax
      1 1 1  5 5 5 5 1                                                                                                                                                                r  Purchase of Existing Business
      1 1 1  6 6 6 6 1                   r  Retail Sales                                                         r    Regular Withholding                                             r  Reinstating Old Business 
      1 1 1  7 7 7 7 1                   r  Temporary Retail Sales (Less than 191 days)                          r    Domestic or Household Employee                                  r  Converted (must have converted
      1 1 1  8 8 8 8 1                   r  Retail Liquor or Alcohol Sales                                       r  Transient Employer*                                                  through the Missouri Secretary of 
      1 1 1  9 9 9 9 1                                                                                                                                                                   State’s office)
                                         Sales or Purchases from an out-of-state location                        Corporate Tax
      2 2 2  0 0 0 0 2                                                                                                                                                                r  Court Appointed Receiver
      2 2 2  1 1 1 1 2                   r     Vendor’s Use                                                      r    Corporate Income
                                                                                                                                                                  Reason for Applying r  Other:
      2 2 2  2 2 2 2 2     Reasonr             Consumer’sfor ApplicationUse (Missouri purchases                  r    Corporate Franchise
      2 2 2  3 3 3 3 2                   where tax is not collected.)
                                                                                                                      * Bond Required            
      2 2 2  4 4 4 4 2 
      2 2 2  5 5 5 5 2                   4. Owner Name (Enter Corporation, LLC or Partnership Name, if applicable)
      2 2 2  6 6 6 6 2 
      2 2 2  7 7 7 7 2                   Address                                                                                       E-mail Address
      2 2 2  8 8 8 8 2 
      2 2 2  9 9 9 9 2                   City                                                                        State             ZIP Code                                        County
      3 3 3  0 0 0 0 3 
      3 3 3  1 1 1 1 3                   If an individual is listed as the owner, you must also provide the following: 
      3 3 3  2 2 2 2 3     OwnerSocialInformationSecurity Number                                                 Date of Birth (MM/DD/YYYY)                 Telephone Number
      3 3 3  3 3 3 3 3                        |        |        |        |        |        |        |        |   ___ ___ / ___ ___ / ___ ___ ___ ___        (___ ___ ___) ___ ___ ___-___ ___ ___ ___
      3 3 3  4 4 4 4 3 
      3 3 3  5 5 5 5 3                   5. Ownership Type               r Sole Proprietor                     r Partnership         r Government           r Trust 
      3 3 3  6 6 6 6 3                       All ownership types listed below, unless specifically exempted, are required to be registered with the Missouri Secretary of State’s Office (register 
      3 3 3  7 7 7 7 3                       at sos.mo.gov or call (866) 223-6535).  Your application will not be complete without providing the charter number issued to you by their office.
      3 3 3  8 8 8 8 3 
                                             r   Limited Partnership - LP Number  __________________________________ 
      3 3 3  9 9 9 9 3                                                                                                                                r   Not Required to register with Missouri Secretary
                                                                                                                                                          of State
      4 4 4  0 0 0 0 4                       r   Limited Liability Partnership - LLP Number ___________________________ 
      4 4 4  1 1 1 1 4                                                                                                                                r Other
                                             r   Limited Liability Company - LLC Number ____________________________ 
      4 4 4  2 2 2 2 4 
      4 4 4  3 3 3 3 4                           Taxed as a              r Disregarded Entity                  r Partnership     r Corporation 
                           Ownership Type
      4 4 4  4 4 4 4 4                       r   Missouri Corporation - Missouri Charter No.  _________________________                                
      4 4 4  5 5 5 5 4                           Date Incorporated (MM/DD/YYYY)  ___ ___ / ___ ___ / ___ ___ ___ ___ 
      4 4 4  6 6 6 6 4 
                                             r   Non-Missouri Corporation - Missouri Charter No. ______________________ 
      4 4 4  7 7 7 7 4 
                                                 State of Incorporation _________________________   Date Registered in Missouri (MM/DD/YYYY)  ___ ___ / ___ ___ / ___ ___ ___ ___
      4 4 4  8 8 8 8 4 
      4 4 4  9 9 9 9 4                   6. Is there a previous owner or operator for the business?                   r Yes*       r   No    *If yes, the following section must be completed.
      4 4 4  0 0 0 0 4 
      5 5 5  1 1 1 1 5                    Select any of the following that you purchased from the previous owner:                     r Inventory   r Fixtures   r Equipment   r Real Estate
      5 5 5  2 2 2 2 5 
                                          r
      5 5 5  3 3 3 3 5                         Other __________________________________________________________________________________________________________
      5 5 5  4 4 4 4 5                                 _____________________________________________________________________ Purchase Price
      5 5 5  5 5 5 5 5 
                                         Name of Previous Owner or Operator                                                                                 Missouri Tax Identification Number 
      5 5 5  6 6 6 6 5 
      5 5 5  7 7 7 7 5                                                                                                                                             |        |        |        |        |        |        |        
                                         Physical Location of Previous Business                                                  City                                                  State             ZIP Code
      5 5 5  8 8 8 8 5 
      5 5 5  9 9 9 9 5     PreviousAddress ofOwnerPreviousInformationBusiness                                                    City                                                  State             ZIP Code
      5 5 5  0 0 0 0 5 
      6 6 6  1 1 1 1 6 
      6 6 6  2 2 2 2 6                                                                                         *14606010001*
      6 6 6  3 3 3 3 6                                                                                                   14606010001
      6 6 6  4 4 4 4 6                                                                                                           1
      6 6 6  5 5 5 5 6 
      6 6 666 6 6 6 

Reporting forms and notices will be mailed to this address.
7. Address (street, rural route or P.O. Box) City State ZIP Code

Company Name if different than owner

Which forms do you want mailed to this address?
 r All Tax Types       r Sales and Use Tax       r Corporate Income Tax       r Employer Withholding Tax
Address where you will store your tax records (do not use a P.O. Box for record storage).
8. Physical Address City State                ZIP Code
Mailing and Storage Address
9. Provide the officers, partners, or members (L.L.C.) of your business who are responsible for the collection and remittance of tax. 
 Listing individuals or entities here indicates they have direct supervision or control over tax matters.  Attach list if needed.
Name (Last, First, Middle Initial)     Title

Social Security Number    Federal Employer ID Number (FEIN) Date of Birth (MM/DD/YYYY)
        |        |        |        |        |        |        |        |                       |        |        |        |        |        |        |        |              ___ ___/___ ___/___ ___ ___ ___
Home Address     City

State  ZIP Code   County  Title Begin Date (MM/DD/YYYY)
___ ___/___ ___/___ ___ ___ ___
Name (Last, First, Middle Initial)     Title

Social Security Number    Federal Employer ID Number (FEIN) Date of Birth (MM/DD/YYYY)
Officers, Partners, or Members         |        |        |        |        |        |        |        |                       |        |        |        |        |        |        |        |              ___ ___/___ ___/___ ___ ___ ___
Home Address     City

State  ZIP Code   County  Title Begin Date (MM/DD/YYYY)
___ ___/___ ___/___ ___ ___ ___
10.  Business Tax Accounts:  Identify all persons who are not a partner, member (L.L.C), or officer of the business that have direct supervision or  
 control over tax matters whom you authorize the Department to discuss your tax matters.  Attach list if needed.
Title Begin or End Date (MM/DD/YYYY)  Name (Last, First, Middle Initial)
__ __ / __ __ / __ __ __ __
Title Social Security Number Birthdate (MM/DD/YYYY)
      |        |        |        |        |        |        |        |        __ __ / __ __ / __ __ __ __
Home Address
Representatives
City       State ZIP Code  County

11. Taxable Sales or Purchases Begin Date (MM/DD/YYYY)  ___ ___/___ ___/___ ___ ___ ___
12. Temporary License (Less than 191 days) (MM/DD/YYYY)
 (Example: fireworks, temporary event, etc.)   Begins ___ ___/___ ___/___ ___ ___ ___       Ends ___ ___/___ ___/___ ___ ___ ___
13. Seasonal Business: If you do not make taxable sales year round, please check the months that you do.
 r January  r February  r March  r April  r May  r June  r July  r August  r September  r October  r November  r December
14. Estimated sales and use tax liability (select one).  Your selection will determine your return filing frequency.
 r Monthly (Over $500 a month)         r Quarterly ($500 or less a month)         r Annual (Less than $200 a quarter)

Retail Sales, Consumer’s or Vendor’s Use Tax

*14606020001*
14606020001
2

 15. Business Name (DBA name: attach list if necessary for additional locations)

Street, Highway (Do not use P.O. Box Number or Rural Route Number) City 

County State ZIP Code Business Telephone Number
(___ ___ ___) ___ ___ ___-___ ___ ___ ___
 16. Will sales be made at various temporary locations in Missouri? 
 r No    r Yes—Attach a list of all known locations. If no Missouri location is given during initial registration, a general location will be used.
17. Is this business located inside the city limits of any city or municipality in Missouri? 
 To verify go to mytax.mo.gov/rptp/portal/home/business/salesUseTaxRateInformation
  r No   r Yes — Specify the city: ______________________________________________________________________ ___
18. Is this business located inside a district(s)?  For example, ambulance, fire, tourism, community or transportation development.
    r No   r Yes — Specify the district name(s):   ________________________________________________________________
19. Describe the business activity, stating the major products sold and services provided. ___________________________________________
Business Name and Physical Location
_________ _______________________________________________________________________________________________________
 r Retail _____%    r Wholesale _____%    r Service  _____%   r Manufacturer   r Contractor   r Other _______________

20. Do you make retail sales of the following items?  Select all that apply.        
 r Alcoholic Beverages    r Alternative Nicotine    r Cigarettes or Other Tobacco Products    r Domestic Utilities
 r E-Cigarettes or Vapor Products    r Food Subject to Reduced State Food Tax Rate    r Items Qualifying for Show Me Green Sales Tax Holiday
 r Items Qualifying for Back-To-School Sales Tax Holiday dor.mo.gov/taxation/business/tax-types/sales-use/holidays/    r Lead-Acid Batteries    
 r New Tires    r Post-Secondary Educational Textbooks    r Telecommunication Services
21. Do you make retail sales of aviation jet fuel to Missouri customers? ........................................................................................... r Yes r No
 If yes, are your sales made at:
 r A Missouri airport?       r A location outside Missouri and the fuel is transported into Missouri?
 If yes, is the airport located in Missouri and identified on the National Plan of Integrated Airport Systems (NPIAS)? ................ r Yes r No
 If yes, provide a list of applicable locations.  _____________________________________________________________________________
Business Activity
22. Do you use, store, or consume aviation jet fuel in Missouri where the seller does not collect tax? ............................................. r Yes r No
 If yes, is the fuel stored, used, or consumed in an airport that is identified on the NPIAS? ......................................................... r Yes r No
 If yes, provide a list of applicable locations:  _____________________________________________________________________________
23. Do you lease or rent motor vehicles that were purchased sales tax exempt, to Missouri customers? ........................................ r Yes r No
 If you are an out-of-state company, will you lease motor vehicles to a Missouri resident where the lease is entered into 
 outside Missouri and the motor vehicle is delivered outside Missouri? ........................................................................................ r Yes r No

If you are an out-of-state entity doing business in Missouri, please answer the following questions.  .
24.  Do you have a location or job site in Missouri? .......................................................................................................................... r Yes r No
  If yes, attach a list of your locations including address, city, state, zip code and indicate if the location is inside or outside 
 the city limits.  ____________________________________________________________________________________________________
24a. Are you a Marketplace Facilitator that facilitates retail sales of tangible personal property or taxable services?  .................  r Yes  r No
 If yes, do you make sales statewide requiring registration of all applicable taxing jurisdictions?   ......................................... r Yes r No
25.  Are orders taken from your Missouri customers by telephone, non-resident salesmen, etc.?  If resident salesmen, attach 
a list where they live and indicate if they are inside or outside the city limits............................................................................. r  Yes r No
26.  Do your representatives who reside in Missouri: 
A.  Approve customer orders? ..................................................................................................................................................... r Yes r No 
B.  Make on the spot sales? ........................................................................................................................................................ r Yes r No 
C.  Maintain an inventory? ........................................................................................................................................................... r Yes r No 
D.  Deliver merchandise to the customer? .................................................................................................................................. r Yes r No
Out-of-State Company
27.  Do you have non-resident representatives, agents, or temporary employees coming into Missouri on a regular basis? ......... r Yes r No
If yes, define the activities performed while in Missouri.  ___________________________________________________________________  
  ___________________________________________________________________________________________________
28.  Do you have real or tangible personal property in Missouri? ..................................................................................................... r Yes r No 
If yes, please describe: ___________________________________________________________________________________

*14606030001*
14606030001
3

                          29. Is this corporation registered with the Internal Revenue Service as a    r Regular or Close Corporation    r Sub Chapter S Corporation

                          30. Corporation Tax Begin Date in Missouri (MM/DD/YYYY)                          Corporation Taxable Year End (MM/DD)
                               ___ ___/___ ___/___ ___ ___ ___                                             ___ ___/___ ___
                          31. Will the corporation be required to make quarterly estimated Missouri income tax payments?  If the Missouri estimated 
 Corporate Income Tax       tax is expected to be at least $250, or 6.25% of the Missouri taxable income, check the “Yes” box. ......................................                                                               r Yes r No

                          32. Missouri Withholding Begin Date (MM/DD/YYYY)                                 How many of your employees will work in Missouri?
                              ___ ___/___ ___/___ ___ ___ ___
                          33. Estimated employer withholding tax liability (select one).  Your selection will determine your return filing frequency.
                              Estimated monthly gross wages _____________________ X 5.4% = __________________________
                              r Annually (less than $100 withholding tax per quarter)                     r Monthly ($500 to $9,000 withholding tax per month)
                              r Quarterly ($100 withholding tax per quarter to $499                       r Quarter-Monthly (weekly) (over $9,000 withholding tax per month; required
                                 per month)                                                                to pay electronically)
                          34. Does a parent company file withholding tax reports and receive full compensation for timely filed returns? ...................................                                                        r Yes r No
                          35. If you do not pay wages year round, please check the months that you do pay wages.
                           r January  r February  r March  r April  r May  r June  r July  r August  r September  r October  r November  r December
                          Withholding Tax Courtesy Mailing Address (a copy of all withholding tax delinquent notices will be mailed to this address)
                          36. Business Name (DBA name)

                          Street, Route or P.O. Box                                                        City 

                          County                                              State                        ZIP Code                         Business Telephone Number
                                                                                                                                            (___ ___ ___) ___ ___ ___-___ ___ ___ ___
                          Transient Employer
                          37. Are you a transient employer?   ..................................................................................................................................................................... r Yes r No 
                              An employer not domiciled in Missouri and temporarily transacting business in Missouri for less than 24 consecutive months is defined as a transient employer.     
 Employer Withholding Tax     (Example: contractor, temporary staffing agency, etc.). For additional information, contact the Department at businesstaxregister@dor.mo.gov or call 
                              (573) 751-0459. If you have indicated that you are a transient employer, you must complete the entire Employer Withholding Tax Section above.
                              A transient employer must submit the following with this application:                                           Missouri Employment Security Account Number 
                              • A completed insurance certification slip indicating Missouri as a covered state for worker’s compensation
                              • Missouri Employment Security Account number, if hiring a Missouri resident: (first seven digits required)
                              • Your Missouri Certificate of Authority Number issued by the corporate division of the Missouri Secretary of State’s Office
                              • A Transient Employer Bond not less than $5,000
                          Calculate your transient employer bond:
                          A. Missouri withholding tax        Monthly gross wages _______________________  X 5.4% = _____________________ X 3 = ____________________________ (a)
                          B. Missouri unemployment tax   Average # of workers __________ X $7,000 = __________________ X 3.38% __________________ / 4 = ___________________ (b)
                          (a) ___________________________ + (b) ___________________ = ______________________________ (amount of bond - minimum $5,000)
                          Visit dor.mo.gov/forms/?formName=&category=13&year=99 for bond forms.
                          Type of bond  r Cash Bond (Form 332)   r Certificate of Deposit (Form 4172)  r Irrevocable Letter of Credit (Form 2879)  r Surety Bond (Form 331)      

                          Comments:

                          Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. This application must be signed by the owner, if the business 
                          is a sole proprietorship, or by an individual listed in the Officer, Partners, or Members section of this application. The signing party is acknowledging that they have direct supervision or 
                          control over tax matters.
                          Signature                                                                 Title                                                   Date (MM/DD/YYYY)
                                                                                                                                                            ___  ___ / ___  ___ / ___  ___  ___  ___
                          Typed or Printed Name                                                     E-mail Address
         Signature
                           Confidentiality of Tax Records
                          Missouri Statute 32.057, RSMo, states that all tax records and information maintained by the Missouri Department of Revenue are confidential. The tax information can 
                          only be given to the owner, partner, member, or officer who is listed with us as such. If you wish to give an employee, attorney, or accountant access to your tax information, 
                          you must supply the Department with a power of attorney to grant the authority to release confidential information to them. Visit dor.mo.gov/forms to obtain a Power of 
                          Attorney (Form 2827).
                             Taxation Division                                                                                                                 Form 2643A (Revised 12-2022)
Mail to: 
               P.O. Box 357                                                    Visit dor.mo.gov/register-business/ for additional information.
              Jefferson City, MO 65105-0357                                    Ever served on active duty in the United States Armed Forces?  
                                                                               If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible 
Phone:  (573) 751-5860
                                                                               military individuals. A list of all state agency resources and benefits can be found at 
    Fax:  (573) 522-1722                                                       veteranbenefits.mo.gov/state-benefits/.
E-mail:  businesstaxregister@dor.mo.gov                                                                                          *14606040001*
                                                                                                    4                                                       14606040001