Rev. 12/09
                             Department of                                                         UT 1000
           hio
                             Taxation                                                              Application for 
                             P.O. Box 182215                                       07100100
                             Columbus, OH 43218-2215                                               Certifi cate of Registration 
                             (888) 405-4089
                                                                                                   for Out-of-State Sellers
                                                                                                Account no.
                                                                                           (For department use only)

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

  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 begin providing taxable sales in the state of Ohio? (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
                             Address of corporation, sole owner, partnership, etc.         City                     State              ZIP code

           Business phone no.                                    Fax no.                                            Secondary phone no.

  7. Mailing address
                             (If different from above)                                     City                     State              ZIP code
  8. How much sales tax do you expect to collect each month?  Less than $200        $200 or greater       

  9. 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

 10. Name, phone number, fax number and e-mail address of individual the department should contact regarding this ac-
    count  

    Name                                               Phone no.                           Fax no.                  E-mail address

 Date                        Signature of applicant

                                                       Mail to the address above.

    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 informa-
tion. We need your Social Security number in order to administer this tax.