CAT 1 
                                                                                                                 Rev. 5/11 
                                                                                                                 Page 1 
                      P.O. Box 16158 
                      Columbus, OH 43216-6158 
                      tax.ohio.gov 

                                           Commercial Activity Tax Registration 
                                            Please complete in black or blue ink – do not use pencil. 

         Federal employer identifi cation number      Social security number (if no FEIN)                                  For state use only 

 1.  Type of organization (check only one):                                     Association/trust           C corporation  LLC                
                                            
                LLP                        LTD (non-U.S.)                       Partnership                 QSSS           S corporation         
                                                                                (other than LLP) 
                Single-member              Sole proprietorship                  Other (please describe) 
                LLC                                                                                                         
 
                      If you selected anything other than sole proprietor, please complete Schedule A. 
  
        2.  Are you a consolidated elected taxpayer, a combined taxpayer or a single entity taxpayer? Check only one. 
                Consolidated elected           Consolidated elected                                          Single entity
                                                                                         Combined 
                with 80% ownership             with 50% ownership                                            taxpayer 
            
    By checking either consolidated box above, the entities listed on Schedule B of this registration hereby 
  elect to fi le a consolidated return. 

      If you are consolidated, are you including your non-U.S. entities (same ownership election as above)? 
                Yes   No            N/A  (currently do not have any non-U.S. entity) 
 3.  If you are a consolidated elected taxpayer or a combined taxpayer, please enter the total number of 
    members, including yourself, and complete Schedule B (attached). 
 4.  A. Legal name of entity (sole proprietor complete 4B):

   B. Sole proprietor: 

     Last name                                                                                   First name                 M.I. 

 5.  Trade name or DBA:  

 6. Primary address: 

     Address of taxpayer’s principal office 

     City                                                                                               State ZIP  code 

     Country (if other than U.S.A.) 

                                                                                                                            Date Received 
                                                                                                                           (For state use only) 
                                                                                                                           M M DD  YY 

                                                                                – over – 

      Federal employer identifi cation number      Social security number                                                  CAT 1 
                                                                                                                          Rev. 5/11 
                                                                                                                          Page 2 

  7. Contact information 
  
  Mailing address (if different from primary) 

  City                                                                                     State ZIP code  
  
  Country (if other than U.S.A.) 
  (              )                            (        ) 
  Offi ce/home phone number                    Offi ce/home fax number 

  E-mail address 
 
 8.  List the state              or country 
    under whose laws the taxpayer is organized (if applicable). 
 9.  If you are registered with the Ohio Secretary of State, enter your charter number, registration number or 
  license-to-conduct-business number: 
 10. NAICS code:                              (For most current NAICS listing, visit us at tax.ohio.gov) 
 11. When did you first become subject to the commercial activity tax? (MM/DD/YY) 

  12. Do you anticipate taxable gross receipts of more than $1 million during the current calendar year? 
          Yes        No 
 
I hereby declare the above to be true and correct to the best of my knowledge and belief. 

Name of applicant or agent (please print)         Signature                                               Date (MM/DD/YY) 

        CAT 1              Schedule A           Rev. 5/11                                                                                                                                                                                                                                                                                      cers, 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      code 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     ZIP 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Country                                                                     State 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Address                                                                     City 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         CAT account no. (if issued) for primary entity: 

                                                                                                                                                   Schedule A – Commercial Activity Tax (CAT) 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Name                                                                        FEIN SSN 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         SSN: 

                                                          P.O. Box 16158                         Columbus, OH 43216-6158              tax.ohio.gov 
                                                                                                                                                                                                                                                                                                                                                     partners or members. If you are a consolidated elected taxpayer or a combined taxpayer, list the information only for the primary entity.                                                                                                                    cer*, general partner, 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         ler: 
                                                                                                                                                                                              Schedule A is to be completed by all taxpayers other than sole proprietorships. Please list the required information for either the corporate offi

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Indicate: Offi                            managing partner or member          *                                                                  President, vice president, secretary, treasurer, statutory agent 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Name of fi                      (as shown on line 4)       FEIN: 

        CAT 1              Schedule B           Rev. 5/11 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   State of organization                                                                                                                                                Country of organization 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 1 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Please make additional copies                                of this schedule as necessary. 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             2 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Type of organization                                                                                                                                                 NAICS code

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ZIP code 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        State 
                                                                                                                                                                                                                                                              and is automatically renewable unless cancelled by the registrant                                                                                                                                                                                                                                      CAT account no. (if issued) of primary                                           entity of consolidated or combined group: 

                                                                                                                                                                                                                                                             eight calendar quarters

                                                                                                                                                   Schedule B – Commercial Activity Tax (CAT)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Address                                                                                                                                                              City                     Country 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Signature of applicant or agent 

                                                                                                                                                                                              Members of Consolidated Elected Taxpayers or Combined Taxpayer 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Social Security No.                                                                                                                                                                           

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     tax.ohio.gov
                                                          P.O. Box 16158                         Columbus, OH 43216-6158              tax.ohio.gov 
                                                                                                                                                                                                                                                             A consolidated election will remain in effect for 
                                                                                                                                                                                                                                                                                                                                or revoked by the tax commissioner. Please complete the information below for each member of the consolidated elected or combined group. 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Federal Employer ID No.                                                                        Name of Member of Consolidated Elected Taxpayer or Combined Taxpayer                           Trade name or DBA                                                                                           I hereby declare the above to be true and correct to the best of my knowledge and belief.                 Date (MM/DD/YY)                 1                                                                                                                                        Organization type (association/trust, C corporation, LLC, LLP, LTD (non-U.S.), partnership, S corporation, sole proprietorship, other) 2 For NAICS codes visit 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Primary entity of consolidated or combined group:                      (as shown on line 4)                                        FEIN: SSN: