Federal Tax ID (EIN) - Allen Corporation Supply, Inc.

Name of Entity*

Trade Name of Business

Only if different than line 1

"Care of" Name

Mailing*

Street Address Address Line 2 City State ZIP Code

Is your Physical Address different than your Mailing Address?*

Yes

No

Physical Address

Street Address Address Line 2 City State ZIP Code

Physical address of business

Name of Principal Officer*

First Last

Social Security Number of Principal Officer*

Please no spaces or special characters allowed.

Type of Entity*

Corp

Professional Corp

LLC

Other

Number of Members in the LLC

Are any of the members' husband and wife

Yes

No

If members' are husband and wife select one of the following

We elect to be classified as a multi-member LLC

We elect to be classified as a single-member LLC

Names of ALL Members

Please list all members on different lines

Have you applied or will you be applying for Subchapter "S" status?*

Yes

No

State where incorporated*

Date Business Started*

Closing Month of Accounting Year*

First date wages were or will be paid*

Highest number of employees within next 12 months*

Principal Activity*

Please be specific

Has applicant ever applied for an EIN before?*

Yes

No

Provide legal name on previous application

Provide the trade name on previous application

Date when filed

City where filed

State where filed

Previous EIN

Name of Person Signing SS-4*

Title of Person Signing SS-4*

Business Telephone Number*

Facsimile Number*

Authorize

I hereby authorize and direct Allen Corporation Supply to complete, affix my signature to, and file an IRS SS-4 form on my behalf, in order to secure an Employer Identification Number for my new entity.

Date*

Signature*

First Last

Federal Tax ID (EIN) Form

Authorize

Services

Products