RENO-SPARKS TRIBAL BUSINESS REGISTRATION FORM



|RENO-SPARKS TRIBAL BUSINESS LICENSE REGISTRATION FORM |

Please print or type the information requested below. Please complete this form and return back to the Tax Dept., Finance Dept., or Tribal Chairman Office and/or Planning Department, accompanied by the appropriate fee(s).

|1.[_]New Business [_]Change Ownership [_]Change Location [_]Change of Name [_]Change of Address [_]Renewal [_]Other: |

|2. Corporate Name: |

|3. Corporate Address: |

|4. Doing Business As: |

|5. Telephone Number: / 6. Federal Tax ID #: |

|7. # of Employees: / 8. New Business - # of Expected Employees: |

|9. Mailing Address: |

|10. Address of Business Operations: |

|11. Address of Business Records: |

|12. Type of Business Entity: [_]Sole Proprietor [_]”S” Corporation [_]Association [_]Partnership [_]Limited Liability [_]Corp-Public [_]Corp-Private |

13. Name of Owner(s), Partners, Corporate Officers, etc.

|Owner, Partner, Officer Name (Last, First, MI) |Residence Address: |

| | |

|Title: DOB: %Owned:| |

|Owner, Partner, Officer Name (Last, First, MI) |Residence Address: |

| | |

|Title: DOB: %Owned: | |

|Owner, Partner, Officer Name (Last, First, MI) |Residence Address: |

| | |

|Title: DOB: %Owned:| |

|Owner, Partner, Officer Name (Last, First, MI) |Residence Address: |

| | |

|Title: DOB: %Owned:| |

14. Date Business Started:_____/_____/_____ **PROJECT/LOCATION:_______________________________***

15. Number of Employees:___________ *Please Indicate which Dept. and/or Project/LocationYou Are Working For***

16. Ownership change, date acquired:_____/_____/_____ In Whole:_____ In Part:_____

17. Name of Previous Owner:_______________________________________________________________________

|18. Describe the Nature of Your Business: (Must Complete this Section) |

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19. Applying for: [ X ] Administration Fee - $15.00 (Per Ordin. #40 Sec. 12-01-04 Fee- “C” …is assessed to each business license issued)

[_] New Business License - $125.00 ($15.00 + $125.00 = $140.00)

TOTAL AMOUNT: [ ] Temp.Bus.License (60days) - $75.00 ($15.00 + $75.00 = $90.00)

$_____________ [_] Foreign Corporation-Certificate of Authority (Must attach Foreign Corp-Supplement Form)

[_] Annual Renewal - $125.00 (RSIC Ordinance #40 - Due January 30th of each year)

[_] Sales/Use Tax Permit - $15.00 (No Expiration Date)

[ ] Late Penalty Fee - $50.00 {not received on or before Jan.30th}

[ ] Contract/Project Work Initiated without securing a Business License Fee - $150.00

I/We certify the information provided on this form is true, correct and complete to the best of my/our knowledge and belief. Further, I/We acknowledge and submit to the jurisdiction of the Reno-Sparks Indian Colony.

|Signature Owner/Officer/Partner: |Typed Name & Title: |Date: |

|Signature Owner/Officer/Partner: |Typed Name & Title: |Date: |

*(2013-BusLicForm4-IncrsFeeTCApproved-Feb12011) FOR OFFICE USE: Check # _____________Amount Rcvd:$_________________

RSIC Finance/Tax Rcpt #:__________________

By:_______________ Date Rcvd:________________

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