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 §§ 43-07-10 and 43-07-11.1, a request for Income, Sales and
Use Tax Clearance Application is made on behalf of:

Taxpayer Legal Name                                                               Federal Employer Identification Number
                                                                                  or Social Security Number

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

Mailing Address                                           City                       State            ZIP Code

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

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

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

Are you making retail sales in North Dakota?        Yes   No

Authorized Signature.  I declare under the penalties of N.D.C.C. § 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 NOTIFICATION
In compliance with the Privacy Act of 1974, disclosure of a social security number or Federal Employer Identification Number (FEIN) on
this form is required under N.D.C.C. §§ 43-07-10, 43-07-11.1 and 57-01-15, and will be used for tax reporting, identification, and
administration of North Dakota tax laws. Disclosure is mandatory. Failure to provide the social security number or FEIN may delay or
prevent the processing of this form.

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