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| What is the trade name of the business, if different from the Legal Name above? |
| Trade Name (if different): | |
| Please provide the full address, including county where the business is formed. |
| Street: | |
| City: | |
| State: | |
| Zip Code: | |
| County: | |
| Please enter the following information about the officer of the company that the IRS may contact, if necessary, for further information. |
| Full Name: | |
| Title of Officer: | |
| Daytime Phone Number: | |
| SSN/EIN of this officer: | |
| If this application is for a limited liability company (LLC), enter the number of LLC members. |
| Number of LLC members: | |
| How is your business owned? Select only one of the options below. |
| Business Type: | |
| Please select one of the reasons below for applying for an EIN |
| Reason for Applying: | |
| If you selected "Started New Business", please specify type: | |
Please provide the month, day, and year the business was started or acquired. |
| Enter Date: | |
| What is the final month of your accounting year? |
| Enter Date: | |
| Please enter the number of employees you anticipate in the next twelve months. If none, please enter a zero. |
| Agricultural: | |
| Household: | |
| Other: | |
Do you expect your employment tax liability to be $1000 or less in a full calendar year?
If you expect to pay $4,000 or less in total wages in a full calendar year, you can mark YES. |
| Please Select: | Yes
No
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| Please provide an estimate of the day, month and year that wages were or will be first paid. |
| Enter Date: | |
| Please describe the business's primary business purpose or activity. |
| Purpose/Activity description: | |
| Has the applicant ever applied for and received an EIN? |
| Please Select: | Yes
No
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| If YES, provide the previous EIN here: | |
