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                                                                                                               Rev. 12/10
                                                                                                      ST 1
                               P.O. Box 182215                     07100100                           Application for Vendor's 
                               Columbus, OH 43218-2215                                                License to Make Taxable Sales
                               (888) 405-4089
                                                                                      Vendor's license no.
 To the County Auditor of                                County                       (For department use only)

      Federal employer identifi cation no.                Social Security no. / ITIN                   Ohio corporate charter no. / certifi cate no.

 If  you fi le under cumulative return authority, what is your master number?
     1.  Check type of ownership:  (10) Sole owner        (20) Partnership        (30) Corporation        (150) Nonprofi t           
       (50) LLC        (70) LLP        (80) LTD        Other (please specify)       
   
     2. When did you or will you start making taxable sales at this location? (MM/DD/YY)    
                                                                                                               (For the most current listings, search 
     3. Provide NAICS code and state nature of business activity                                               NAICS on our Web site at tax.ohio.gov.)
  
     4. Legal name 
                    (Corporation, sole owner, partnership, etc.)
     5. Trade name or DBA
     6. Primary address
                                                                                      City State ZIP code
                               Address of corporation, sole owner, partnership, etc.

              Business phone no.                                   Fax no.                                     Secondary phone no.
     7. Mailing address
                               (If different from above)                              City                      State                  ZIP code
     8. Business location
                               Address                                                City                      State                  ZIP code
     9. How much sales tax do you expect to collect each month?  Less than $200        $200 or greater       
   10.  Have you applied for a liquor permit transfer?  Yes        No                                           
      
       Vendor's license number                                     Liquor permit no.    
  11a. Have you applied for a new liquor permit?  Yes        No                       Date applied for
  11b. Do you intend to make nonliquor sales prior to the issuance of your new liquor permit?  Yes        No
       Date business will or did begin   
   12. If you operate as a corporation or partnership, list appropriate names, addresses and identifi cation numbers below.

      Title         Name                       Street              City                State          ZIP code           SSN / ITIN / FEIN

      Title         Name                       Street              City                State          ZIP code           SSN / ITIN / FEIN

      Title         Name                       Street              City                State          ZIP code           SSN / ITIN / FEIN
 13. Name, phone number, fax number and e-mail address of individual the department should contact regarding this account  

     Name                                                Phone no.                    Fax no.                   E-mail address

   Note: The county auditor shall not issue a vendor's license until all questions on this application are answered. Application 
   and payment of the $25 fee must accompany this application.

 Date               Signature of applicant                         County auditor                              By deputy