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 offi ce

     City                                                                                              State ZIP code

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

                                                                                                                               Date Received
                                                                                                                              (For state use only)
                                                                                                                              M M DDY       Y

                                                                                – 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 fi rst 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
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     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.                                                                                              
                                                                                                                                                                                                                                                                                                                                                                                                                                                           ler:
                                                                                                                                                        Schedule A is to be completed by all taxpayers other than sole proprietorships. Please list the required information for either the corporate offi cers, 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Indicate: Officer*, general partner, 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: