1. Please give us three names for your corporation in order of preference. This is just in case one or two of the names is already taken.
   a)_______________________________________________________________________
   b)_______________________________________________________________________
   c)_______________________________________________________________________
   

2. Name of Incorporator(s)______________________________________________
   _________________________________________________________________________
   

3. Mailing Address______________________________________________________
   City________________________________________State_______ ZipCode_________
   

4. Daytime Phone:____________________ FAX:______________________
   (Please include area code.)

   Valid E-mail Address:_______________________________________________________________

5. Actual Business Address _____________________________________________
   _________________________________________________________________________
   City________________________________________State_______ County_____________ ZipCode_________
   

6. The following information is for the IRS to fill out their form #SS-4 which is the application for an Employer Identification Number (EIN), also known as a Federal Tax ID Number:

7. Name of principal officer/president______________________________________
   Principal officer/president's Social Security Number:______________________
   

8. Reason for applying:
   

   _____Started New Business
   _____Hired Employees
   _____Created Pension Plan - Specify type__________________________
   _____Banking Purpose - Specify_________________________________
   _____Purchased Ongoing Business
   _____Changed Type of Organization
   _____Created a Trust: (specify)_________________________________________ _____________________________________________
   

9. Enter closing month of accounting year______________________. (This is usually December 31st or the end of the month of incorporation, or if your business is seasonal and for example, your earnings peak in July, then you might want to use July 31st.

10. Principal activity of the business_______________________________________
    _________________________________________________________________________
    
11. Is the principal activity Manufacturing? _____Yes _____No
    If yes, principal product and raw material used:_________________________
    _________________________________________________________________________
    

12. Highest number of employees expected in the next 12 months_______________
    

    ________Nonagricultural
    ________Agricultural
    ________Household
    

13. First date (mo/day/year) wages or annuities were or will be paid _____________________

14. To whom most of the products are being sold:
    ___Public ___Other (specify)_____________________________________________
    

15. Has applicant ever applied to an identification number for this or any other business? _____Yes _____No
    If yes, give detailed explanation, name of business, trade name, month, year, city, state, previous EIN (Tax ID#)______________________________________
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
    

    
    CREDIT CARD PAYMENTS please complete information below:

    _____ Regular handling ($599.95) _____ Expedited handling ($699.95)

    If paying by credit card, this charge will reflect as Media House.

    Name as it appears on credit card:____________________________________________________________

    Billing address:___________________________________________________________________________

    City_____________________________ State ______ Zip ________________

    Card No.: __________________________________________ Expiration Date:_________________________

    Signature:_________________________________________________________________

    Don't forget to include the Specific Power of Attorney for IRS.

    For Signature Page, Click Here .

    
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