TRI-STATE FINANCIAL GROUP, LLC                                              Tax forms and other information available at 
                      PO BOX 38                                                                       www.tfgtax.com 
                                                                                                 Phone 610-270-9520 
             BRIDGEPORT, PA 19405                                                                Fax     610-270-9522 
                BUSINESS REGISTRATION/MERCANTILE LICENSE APPLICATION 
 •   ANSWER ALL QUESTIONS COMPLETELY. INCOMPLETE APPLICATIONS WILL NOT BE APPROVED 
 •   A SEPARATE APPLICATION MUST BE FILED FOR EACH COMPANY DOING BUSINESS 
 
 1.  BUSINESS NAME (Enter name under which business is conducted): __________________________________________________ 
 2.  COMPLETE ADDRESS OF ACTUAL BUSINESS LOCATION IN BETHLEHEM CITY (No PO Boxes, if none, write NONE): 
     ___________________________________________________________________________________________________________________ 
 3.  EIN / SSN:  ________________________________________________________ 
 4.  MAILING ADDRESS (If different than above): 
     _______________________________________________________________________________________________________ 
 5.  ADDRESS OF CORPORATE OFFICE: 
     _______________________________________________________________________________________________________ 
 6.  PHONE NUMBERS: Local office (______)__________________________ E-Mail____________________________________ 
 7.  DESCRIPTION OF BUSINESS ACTIVITY ___________________________________________________________________ 
 8.  DOES THIS BUSINESS HAVE OTHER LOCATIONS: (    ) Yes (    ) No   If YES , where are the other business locations: 
     (    ) In Pennsylvania     (    )   Other __________________________________________________________________________ 
 9.  BUSINESS TYPE:  (    ) Sole Proprietorship  (   ) Partnership  (    ) C Corp  (    ) S Corp  (    ) LLC  (    ) Non-Profit 
 10. DATE STARTED IN BETHLEHEM CITY:  _________________________ 
 11. NUMBER OF EMPLOYEES AT THIS LOCATION: (Including self-employed, partners and owners) _____________________ 
 12. DO YOU RENT THE OFFICE SPACE OF BUILDING YOU OCCUPY? (    ) Yes  (    ) No  If YES, give name and address of 
     landlord or rental agent ____________________________________________________________________________________ 
 13. IS THIS BUSINESS A:  (    ) Retail  (    ) Wholesale  (    ) Service  (    ) Rental Income  (    ) Manufacturer 
 14. DO YOU OWN ANY PROPERTY IN BETHLEHEM CITY FOR WHICH YOU RECEIVE RENTAL INCOME? 
     (    ) Yes (    ) No   If  YES, give name of owner or rental agent ____________________________________________________ 
 15. ARE THERE ANY LEASED DEPARTMENTS OR CONCESSIONAIRES AT THIS LOCATION?  (    ) Yes  (    ) No 
     If YES, please provide name and address of provider ____________________________________________________________ 
 16. ARE THERE ANY SUB-CONTRACTORS PERFORMING SERVICES ON YOUR BEHALF IN CITY?  (    ) Yes  (    ) No 
     If YES, please provide name and address of sub-contractor _______________________________________________________ 
      
     **All businesses and/or employers in the City of Bethlehem are required to register with the           
     Tri-State Financial Group. A Registration Fee of $25.00 must accompany this Registration Form** 
      
             TOTAL AMOUNT DUE WITH APPLICATION                                                          $ ____25.00_____ 
      
     **If you have a PA HIC License you do not need to pay the $25.00 Registration Fee –  
         Please provide following: PA HIC #: ____________________;   Expiration                         ______________ **   
                                                                                          
                      Enclose check made payable to “CITY OF BETHLEHEM” –  
                                                                   
                 Mail to Tri-State Financial Group, PO Box 38, Bridgeport, PA 19405 
                                                                   
Print Name (Owner or Authorized Person): ________________________________________________     Date _________________ 
 
Signature (Owner or Authorized Person): _________________________________________________      Title  _________________