Rev. 11/17
                                                                                         IT 1
                                                                                         Application for Registration 
                            P.O. Box 182215                      07100100
                            Columbus, OH 43218-2215                                      as an Ohio Withholding Agent
                            (888) 405-4089
                                                           Reset Form

                                                                                             (For department use only)

Federal Employer  dentificationI Number     Secretary of State Entity Number

Check here to reactivate an account                 Provide account number to reactivate.

1. Check type of ownership:       Sole owner        Partnership        Corporation        Nonprofit        LLC        LLP        LTD 
        Single member LLC            Other (please specify)     

2. Date of first Ohio payroll (MM/DD/YY)
                                                                                             (For the most current listing, search 
3. Provide NAICS code and state nature of business activity                                  NAICS on our website at tax.ohio.gov)

4. Legal name of business
5. Trade name or DBA
6. Primary address of business
                                     Street                              City                       State             ZIP code

               Business phone number                       Fax number                                  Secondary phone number
7. Mailing address
                    Street                                                    City                State               ZIP code
8. Check the box applicable to your estimated employer withholding remittance amount per year:
            $2,000 or less                  Greater than $2,000, but less than $84,000              At least $84,000

9. Information for individual responsible for filing returns and making payment of Ohio and school district withholding taxes:

   Name                                             Title                   Phone number                  SSN / ITIN

        Street                                                                City           State                  ZIP code
  10. Name, phone number, fax number and e-mail address of individual the department should contact regarding this account

   Name                                             Phone number            Fax number              E-mail address
   Date                              Signature of applicant

                                                    Federal Privacy Act Notice
                 Because we require you to provide us with a Social Security number, the Federal Privacy 
                 Act of 1974 requires us to inform you that providing us with your Social Security number is 
                 mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize us to 
                 request this information. We need your Social Security number in order to administer this tax.