APPLICATION TO OBTAIN CONTRACTOR'S
REQUEST FOR CLEARANCE
NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER
SFN 59937 (Revised 6/11)
                                                                                                FOR OFFICE USE ONLY

Pursuant to North Dakota Century Code § 43-07-11.1, as amended, a request for Income, Sales and Use Tax Clearance
Application is made on behalf of:

1. Taxpayer Legal Name                                                                              2. Federal Employer I.D. Number (FEIN)
                                                                                                        or Social Security Number

3. Doing Business As Name (if different from line 1)                                                4. Business Telephone Number

5. Mailing Address                                               City                               State          Zip Code

6. Organization Type     Sole Proprietorship                 General Partnership                LLC        Corporation
                         Partnership                         Government                         Association
7. Description of Business (list all types of activity)

8. Have business activities been conducted in North Dakota anytime during the past three years? Yes                No

9. Do you have employees earning a wage in North Dakota?     Yes                 No

10. Are you making retail sales in North Dakota?       Yes       No

Authorized Signature.  I declare under the penalties of North Dakota Century Code ch. 12.1-11-02, which provides for a Class A misdemeanor for
making a false statement in a governmental matter, that this application, including any accompanying schedules and statements, has been examined by
me and to the best of my knowledge and belief is a true, correct and complete application.

Print Name of Authorized Individual                    Title                                               Telephone Number

Signature                                                                                                  Date

Privacy Act information.  In compliance with the Federal Privacy Act of 1974 (Public Law 93-579), the disclosure of an individual’s social security
number on the North Dakota income tax return and any required schedules is mandatory and is required under subsections 1 and 7 of North Dakota
Century Code §57-38-31.  An individual’s social security number is used as an identification number by the North Dakota Office of State Tax
Commissioner for file control and recordkeeping purposes, and for cross-checking an individual’s files with those of the Internal Revenue Service.

Mail to:   Office of State Tax Commissioner                             Contact:   Fax: (701)328-0332
              Business Registration                                                             Phone: (701)328-1241 - Sales
              600 E. Boulevard Ave., Dept. 127                                         Web site: www.nd.gov/tax
              Bismarck, ND 58505-0599                                                  Email: taxregistration@nd.gov