NEVADA BUSINESS REGISTRATION

[Pages:1]NEVADA

Important details are included in the instructions. information depending on your type of business. requirements relating to your business.

BUSINESS REGISTRATION

Please type or print in black ink. Each agency may request Completing this form does not relieve you of any statutory or

additional regulatory

I Am Applying For:

Corporate/Entity Name:

(Employment Security Division -ESD)

Modified

0 Location

S Corp.

Business Tax

Changein 0 Name

(Departmentof Taxation)

SEND A COpy TO EACH AGENCY

Change in

D Other

Corporate Officers -

Mailing Address

0 LimitedLiability0 LimitedLiabilit1y0 GovernmeTn~t

Partnership --.S:2!!!-P~~~~-

I Corporate/Entity

Telephone \

Corporate/Entity Address: ".

Nevada Name (DBA):

E-mail Address:

Website Address:

State of Incorporation or Formation

I Business Telephone

I Fax

Mailing Address:

uite, Unit or Apt #

t;ity, State, and Zip Code +4

City. State. Zip +4

' ."I:

IllIe

Percent Owned

:

lephone

Residence Address (Street)

SSN:

irth

City. State. Zip +4

lephone

Mesidence Address (Street)

SSN:

Date of Birth

Title

City. State. Zip +4

lephone

Mesidence Address (Street). City, State. Zip +4

SSN:

I Residence Telephone

Date Business Started in Nevada! Date Business Location Opened I Date First Worker Hired in Nevada I

Amount of First Nevada payroll! Number of Employees

Domestics I

0 Service 0 Agriculture 0 0 Tobacco 0 Manufacturing 0

g Delivery 0 Transportation 0 r-- Not for Profit I'.

PLEASE CHECK ALL THAT APPLY TO YOUR BUSINESS

! Water Appropriation

Home Occupation

HazardousMaterial

0 Leased or Leasing Employees

Retail Sales-New U Construction/Erection 0 Leasing (Other than Employees)

0

Retail Sales-Used -Telephone Solicitation ~. Environmental Discharg~

g

~upply/UseTemporaryWorkers

0

Gaming Health Services

0 FinancialInstitutions 0 MortgageBrokers g Banker

Describe in Detail the Nature of Your Business in Nevada. Include Product Sold, Labor Performed and/or Setvices Rendered.

State the approximate percentage of sales or revenues resulting from each item. Example: Retail sale of major appliances to public 60%; repair 40%.

Date Acquired/Changed: Name(s) of Previous Owner(s) Address (~treet) I:nter

Acquired/Changed by: City

Purchase

Portion Acquired/Changed:

Previous Owner(s) Business Name

0 In Whole Din Part

State

Lip Code+4

"Signatures

must be original and that of a responsible party. If a general partnership Legal signatures include: sole proprietor-owner, corporate Print Name And Title

or joint venture, more than one signature officer, and managing member.

~:SignatuRreeSPOnS:i~b::::::~,:-

"Signature Responsible Party I Original

Title

is required. Date Date

ORIGINAL SIGNATURES REQUIRED BY AGENCIES-KEEP

COpy FOR YOUR RECORDS APP-O1.00RevO2-17-05

..~0_ll~L:~=

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download