2022 RESELLER'S PERMIT TAX ID NUMBER

1Company

2Select State(s)

3Business Structure

4Address

5Owner(s)

6Company

7Signature

Company Information
Company Name*
Company DBA Name - " Doing Business As "
Does the above Company conduct business under a different name
Enter Company DBA - Doing Business As - Name
Company Contact E-mail*
Enter Email Confirm Email

Select State for Registration
Please Select State for Registration ( Required )*
Please select the State the business is requesting for new registration.
Total: Registration & Fees
$0.00
Expedited Services is included at no additional charge - Payment is by Credit Card only at this time.
Is the Company seeking to register in One single state?*
Typically, most new businesses register in one state.
- Yes, One Single State Application
- Multiple State ( Two or more ) Applications
For Additional Registrations, please select the States below. This is optional and only applies if you wish to register in more than one state.
Please Select Second State Registration ( Optional )
Please select the Second State the business is requesting for new registration ( Optional )
Please Select Third State Registration ( Optional )
Please select the Third State the business is requesting for new registration ( Optional )
Total: Registration & Fees
$0.00
Expedited Services is included at no additional charge - Payment is by Credit Card only at this time.

Select Business Structure
Select Business Structure*
- Sole Proprietor - A Single Owner / Proprietor
- Partnership - Two (2) + Persons, without a Corporate Structure
- Corporation
- Limited Liability Corporation
State of Partnership Agreement
State of ( or proposed State ) the Partnership will operate and conduct business
State of Incorporation
State of Filing ( or proposed State of filing )
State of Limited Liability Corporation
State of Filing ( or proposed State of filing )
Business Start Date*

Ownership Information
Owner Name*

First Last
Owner's Date of Birth*
Owner Social Security Number*
Please include hyphens XXX-XX-XXX ; for verification purposes.
Owner Address same as Physical Business Address*
Owner Address
Street Address City ZIP Code
Owner #2- Information
Owner #2- Name*

First Last
Owner's Date of Birth*
Owner #2 Social Security Number
Please include hyphens XXX-XX-XXX ; for verification purposes.
Owner #2- Address same as Physical Business Address*
Owner #2- Address
Street Address City ZIP Code

Payment Information
Total Amount*
$0.00
Phone Number - For Company Verification*
A representative may call this number to verify the information.
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Driver License Number*
Credit Card Billing Address*
Please enter the billing address of the credit card.

Street Address City ZIP Code
Credit Card Authorization Consent Agreement*

***** Please scroll and read and agree to the Credit Card Authorization Consent Agreement

I am an authorized user of the credit card. “ I “ refers to the cardholder / authorized user.

I understand my card will be pre-authorized, and a hold will be placed on the credit card for the exact amount of the charge.

I understand the information is verified on the application for errors. At times, the information verification process may add additional time. I understand this may create a delay in the processing of the application.

I understand as this is a unique service for the business information entered, and a refund will be issued only if the business is registered, or if the application for the company is rejected; if this applies to your application, your card will either not be charged or will be refunded.

I understand the information must be verified on the application submitted, and any errors, intentional or otherwise, may create a delay in the processing of your application.

Once the application is reviewed and the application is processed, I understand I will receive an email confirmation, at which point my credit card will be charged.

I am authorizing a single, one (1) time credit card charge to be processed through License Tax Sales Services.

I understand no additional charges will be authorized, and only the last four digits of the credit card are kept on file, solely for record keeping purposes.

I authorize a charge for the above amount to the credit card indicated in this authorization form according to the terms outlined above.

This payment authorization is for the services described above, for the amount indicated above only, and is valid for one time use only.

I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

This authorization is for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Accept Consent for Credit Card Authorization Consent Agreement ( required )
Please note charges will appear on the credit card as* Licensing Registration Services *
{Company Name:9} - Application
Consent & Signature
Electronic Processing Consent*

***** Please read and scroll and agree to Electronic Processing

(i) the information entered has been reviewed and is deemed true,

(ii) represent and warrant the information provided above is accurate,

(iii) agree to be bound by the privacy terms of use of this web portal,

(iv) receive / deliver the registration(s) if /when applicable electronically and/or physically for the person / entity listed above for the selected electronic request(s),

(v) and/or when applicable selected and/or submitted of the person or entity entered,

(vi) answer any questions entered on the selected application(s) on behalf or the behalf of the entity entered / listed for the selected application(s), if necessary, when applicable, about the completion of selected application(s),

(vii) information submitted, is accurate and deemed to be true, as best to the knowledge of the applicant / authorized user / authorized entity,

(viii) understand, if necessary when applicable, for the application(s) selected, hereby authorize a "Third Party Designee” for the application(s) and/or registration(s),

(ix) submission of form, as unique individual application(s) / registration(s), entity ( or authorized individual ) understand this application(s) / fees / charges / information may not be changed / disputed, as each form application(s) / registration(s) is unique to the individual and / or entity applying.

I agree to the electronic consent authorization to process request and submitting this form, you ( or entity ) agree to the electronic submission of the selected application(s) and/or registration(s) requests, and/or if applicable.

Accept Electronic Consent for Submission
Authorized Electronic Signature*

2023 Retail & Wholesaler Resale Sales Tax Permit Number

Company Information

Select State for Registration

Select Business Structure

Company Address and Phone

Ownership Information

Payment Information

Consent & Signature