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PA-100 (03-09)

MAIL COMPLETED APPLICATION TO:

DEPARTMENT OF REVENUE

BUREAU OF BUSINESS TRUST FUND TAXES

PO BOX 280901

HARRISBURG, PA 17128-0901

TYPE OR PRINT LEGIBLY, USE BLACK INK

COMMONWEALTH OF PENNSYLVANIA

PA ENTERPRISE

REGISTRATION FORM

DEPARTMENT USE ONLY

RECEIVED DATE

DEPRTMENT OF REVENUE & DEPRTMENT OF LR D INDUSTRY

SECTION 1 – REASON FOR THIS REGISTRATION

REFER TO THE INSTRUCTIONS E D CHECK THE ICE BOXTO INDI

CTE THE RENFOR THIS REGISTRTION.

.	NEW REGISTRTION
.		DING T& SERVICE
.		RETIVTING T& SERVICE

4. DING ESTISHMENT

5. INFORMTION UPDTE

6. DID THIS ENTERPRISE:
YES	NO	QUIRE L OR PRT OF OTHER BUSINESS?
YES	NO	RESULT FROM CHGE IN LEG STRUCTURE OR EXE FROM INDIVIDU
		PROPRIETOR TO CORPORTION PRTNERSHIP TO CORPORTION COR	PORTION
		TO LIMITED LILITY COMPYETC
YES	NO	UNDERGO MERGER CONSOLIDTION DISSOLUTION OR OTHER REST	RUCTURING?

SECTION 2 – ENTERPRISE INFORMATION

DTE OF FIRST OPERTIONS

. DTE OF FIRST OPERTIONS IN P

ENTERPRISE FISC YE END

ENTERPRISE LEG N

5. FEDER EMPLOYER IDENTIFICTION NUMBER N

6. ENTERPRISE TRE Nf different than legal name

. ENTERPRISE TELEPHONE NUMBER

ENTERPRISE STREETDRESS

do ot use PO Box

CITY/TOWN

COUNTY

STTE

ZIP CODE + 4

. ENTERPRISE MLING DRESS f different than street address

CITY/TO

STTE

ZIP CODE + 4

. LOCTION OF ENTERPRISE RECORDS reet address

CITY/TOWN

STTE

ZIP CODE + 4

. ESTISHMENT Noing business as

. NUMBER OF

PSCHOOL DISTRICT

4. P

MUNICIPLITY

ESTISHMENTS *

*ENTERPRISES WITH ONE OR MORE ESTABLISHMENTS WITHIN PA, WHOSE PA ADDRESS WAS NOT ENTERED ABOVE, MUST COMPLETE SECTION 17 (SEE GENERAL INSTRUCTIONS AND SECTION 17 FOR MORE INFORMATION)

SECTION 3 – TAXES AND SERVICES

LL REGISTRTS MUST CHECK THE ICE BOXTO INDICTE THE TD SERVIC	EREQUESTED FOR THIS REGISTRTION D CO	MPLETE THE
CORRESPONDING SECTIONS INDICTED ON PES D . IF RETIVT	ING Y PREVIOUS COUNT LIST THE COUNT NUMBERIN THE SPE PROVID	ED.

	PREVIOUS
	ACCOUNT NUMBER
CIGETTE DEERʼS LICENSE
CORPORTION T
EMPLOYER WITHHOLDING TX
FUELS TPERMIT
LIQUID FUELS TPERMIT
LIQUID FUELS TPERMIT
MOTOR CRIERS RO TIFT
PROMOTER LICENSE
PROMOTER LICENSE
PUBLIC TRSPORTTION
PUBLIC TRSPORTTION
STCE TLICENSE
STCE TLICENSE
SES TEXEMPT STTUS

SECTION 4 – AUTHORIZED SIGNATURE

ACCOUNT NUMBER

SES USE HOTEL OCCUPCY

TLICENSE

SML GOF CHCE LIC./CERT.

TRSIENT VENDOR CERTIFICTE

UNEMPLOYMENT COMPENSTION

USE TX

VEHICLE RENTTX

WHOLESER CERTIFICTE

WORKERSʼ COMPENSTION COVERE

I ETHE UNDERSIGNED DECLE UNDER THE PENTIES OF PERJURY THT TH		E STTEMENTS CONTNED HEREIN E TRUE CORRECTD COM		PLETE.

THORIZED SIGNTURETTH POWER OFTTORNEY IF ICE	DYTIME	TELEPHONE NUMBER	TITLE

TYPE OR PRINT N

ELDRESS

DTE

TYPE OR PRINT PREPERʼS N

TITLE

DYTIME TELEPHONE NUMBER

ELDRESS

DTE

PA-100 (03-09)		DEPRTMENT USE ONLY
		DEPRTMENT USE ONLY
ENTERPRISE N

SECTION 5 – BUSINESS STRUCTURE

CHECK THE OPRITE BOX FOR QUESTIONS & . IN DITION TO SEC

TIONS THROUGH COMPLETE THE SECTIONINDICTED.

. SOLE PROPRIETORSHIP NDIVIDU	GENER PRTNERSHIP	CITION
CORPORTION c.	LIMITED PRTNERSHIP	BUSINESS TRUST
GOVERNMENT c.	LIMITED LILITY PRTNERSHIP	ESTTE
	JOINT VENTURE PRTNERSHIP

LIMITED LILITY COMPY

STTE WHERE CHTERED

RESTRICTED PROFESSION COMPY

STTE WHERE CHTERED

.	PROFIT
.	YES

NONOFIT	IS THE ENTERPRISE ORGIZED FOR PROFIT OR NONOFIT?
NO	IS THE ENTERPRISE EXEMPT FROM TTION UNDER INTERN REVENUE CODE RCSEC	TION 5 IF YES
	PROVIDE COPY OF THE ENTERPRISE'S EXEMPTION THORIZTION LETTER FROM T	HE INTERN REVENUE SERVICE.

SECTION 6 – OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTY INFORMATION

PROVIDE THE FOLLOWING FOR ALL INDIVIDUD/OR ENTERPRISE OWNERS PRTNERS SHEHOLDERS OFFICERS

D RESPONSIBLE PRTIES. IF STOCK IS PUBLICLY

TRED PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE ADDITIONAL SPACE IS AVAILABLE IN SECTION 6A, PAGE 11

. SOCI SECURITY NUMBER

DTE OF BIRTH *

4. FEDER EIN

OWNER

OFFICER

6. TITLE

. EFFECTIVE DTE

PERCENTE OF

. EFFECTI

VE DTE OF

PRTNER

SHEHOLDER

OF TITLE

OWNERSHIP

RESPONSIBLE PRTY

. HOME DRESS reet

CITY/TOWN

COUNTY

STTE

ZIP CODE + 4

. THIS PERSON IS RESPONSIBLE TO REMIT/MNTN:

SES T

EMPLOYER WITHHOLDING TX

MOTOR FUEL T

WORKERSʼ COMPENSTION COVERE

* DTE OF BIRTH REQUIRED ONLY IFYING FOR CIGETTE WHOL

ESE DEERʼS LICENSE SML GOF CHCE DISTRIBUTOR LICENSE OR SML

OF CHCE MUFTURER CERTIFICTE.

SECTION 7 – ESTABLISHMENT BUSINESS ACTIVITY INFORMATION

REFER TO THE INSTRUCTIONS ON PAGES 20 & 21 TO COMPLETE THIS SECTION COMPLETE SECTION 17 FOR MULTIPLE ESTABLISHMENTS

. ENTER THE PERCENTE THT EH

PABUSINESS ACTIVITY REPRESENTS OF THE TOTL RECEIPTS OR REVENUEST

THIS ESTISHMENT. LIST

PRODUCTS OR

SERVICES CITED WITH EH BUSINESS TIVITY D THE PERCENTE REPRESENTING THE TO

TL RECEIPTS OR REVENUES.

PA BUSINESS ACTIVITY

PRODUCTS OR SERVICES

ADDITIONAL

PRODUCTS OR SERVICES

mmodation & Food Services

riculture Forestry Fishing & Hunting

Entertainment & Recreation Services

Communications/Information

Construction st complete question

Domestics vate Households

Educational Services

Finance

Health Care Services

Insurance

Management Support & Remediation Services

Manufacturing

Mining Quarrying & Oil/Gas Extraction

Other Services

Professional Scientific & Technical Services

Public ministration

Real Estate

Retail Trade

Sanitary Service

Social stance Services

Transportation

Utilities

Warehousing

Wholesale Trade

TOTL

. ENTER THE PERCENTE THT

THIS ESTABLISHMENTS RECEIPTS OR REVENUES REPRESENT OF THE TOTAL PARECEIPTS OR REVENUES OF THE ENTERPRISE.

______________%. SINGLE ESTBLISHMENT ENTERPRI SES ENTER %. MULTIPLE ESTISHMENT ENTERPRISES ENTER PERCENTE OF ENTERPRISE SEC

TION

. ESTISHMENTS ENGED IN CONSTRUCTION

MUST ENTER THE PERCENTE OF CONSTRUCTION TIVITY THT IS NEW D/OR

RENOVTIVE D THE PERCENT

E OF CONSTRUCTION TIVITY THT IS RESIDENTID/OR COMMERCI

___________________% NEW

__________________% RENOVTIVE

___________________% RESIDENTIL

__________________% COMMERCIL

4. YES NO

DOES THIS ENTERPRISE WNT TO BECOME PENNSYLVNILOTTERY

RETLER?

PA-100 (03-09)		DEPRTMENT USE ONLY
		DEPRTMENT USE ONLY
ENTERPRISE N

SECTION 8 – ESTABLISHMENT SALES INFORMATION


.	YES	NO	IS THIS ESTISHMENT SELLING TE PRODUCTS OR OFFERING TE SERVICES TO		CONSUMERS FROM LOCTION
			IN PENNSYLVANIA? IF YES COMPLETE SECTION .
.	YES	NO	IS THIS ESTISHMENT SELLING CIGETTES	IN PENNSYLVANIA? IF YES COMPLETE SECTIONS D .

. LIST EH COUNTY	IN PENNSYLVANIA WHERE THIS ESTISHMENT IS CONDUCTING TE SES TIVITYES
COUNTY		COUNTY	COUNTY
COUNTY		COUNTY	COUNTY
		ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.

SECTION 9 – ESTABLISHMENT EMPLOYMENT INFORMATION

PART 1

. YES

NO	DOES THIS ESTISHMENT EMPLOY INDIVIDUS WHO			WORK IN PENNSYLVANIA? IF YES INDICTE:
	a.	DTE WES FIRST	PAID DD/YYYY	. . . . . . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

	b.	DTE WGES RESUMED FOLLOWING BREIN EMPLOYMENT			. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

	c.	TOTL NUMBER OF EMPLOYEES		. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . .

	d.	NUMBER OF EMPLOYEES PRIMILY WORKING IN NEW BUILDING OR INFRRUC				TURE

e.NUMBER OF EMPLOYEES PRIMILY WORKING IN REMODELING CONSTRUCTION . . . . . . . . . . . . . . . . . . . . . .

f. ESTIMTED GROSS WGES PER QUTER

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .$

g.NOF WORKERSʼ COMPENSTION INSURCE COMPY


.	POLICY NUMBER _________________________________E FFECTIVE STRT DTE __________________END DTE __					_________________
.	GENCY NME _____________________________________ _________________DYTIME TELEPHONE NU MBER ______________________
	MLING DRESS		_____________________________________CITY/TOWN ______________________STTE _____ZIP CODE + 4_ _______
.	IF THIS ENTERPRISE DOES NOT HVE WORKERSʼ COMPENSTIONINSURCE CHECK				ONE:
	a.	THIS ESTISHMENT EMPLOYSONLY EXCLUDED WORKERS . . . .		. . . . . . . . . . . . . . . . . . . . . . .
	b.	. . . . . . . . . . . . . .THIS ESTISHMENT HZERO EMPLOYEES		. . . . . . . . . . . . . . . . . . . . . . . . . .

c.THIS ESTISHMENT RECEIVED OVTO SELFNSURE BY THE PBURE OF

		WORKERSʼ COMPENSTION		. . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		IF ITEM c. IS CHECKED PROVIDE PWORKERSʼ COMPENSTION BURE CODE
NO	DOES THIS ESTISHMENT EMPLOY PRESIDENTS WHO				WORK OUTSIDE OF PENNSYLVANIA?
	IF YES INDICTE:
	a.	DTE WES FIRST	PAID DD/YYYY . . .	.	. . . . . . . . . . . . . . . . . .	.	. . . . . . . . . . . . . . . . . . . . . .
	b.	. . . . . . . .DTE WGES RESUMED FOLLOWING BREIN EMPLOYMENT					. . . . . . . . . . . . . . . . .
	c.	ESTIMTED GROSS WGES PER QUTER.		. . . . . . . . . . . . . .		. . . . . . . . . . . . . . . . . . . . . . . . . . .$		.
NO	DOES THIS ESTISHMENT PY REMUNERTION FOR SERVICES TO PERSONS YOU DO						NOT CONSIDER EMPLOYEES?
	IF YES EXPLN THE SERVICES PERFORMED

PART 2

. YES	NO	IS THIS REGISTRTION		RESULT OF TE DISTRIBUTION FROM	BENEFIT TRUST DEFERRED PYMENT OR RETIREMENT PL
		FOR PRESIDENTS?
		IF YES INDICTE:	a.	DTE BENEFITS FIRST PAID DD/YYYY		. . . . . . . . . . .

			b. ESTIMTED BENEFITS PID PER QUTER		. . . . . . . . . . . . . . . . . . . . . .$	.

	SECTION 10 – BULK SALE/TRANSFER INFORMATION
IF S WERE QUIRED IN BULK FROM MORE TH ONE ENTERPRISE PHOTOCOPY T				HIS SECTION D PROVIDE THE FOLLOWING INFORMTION		UT EH
SELLER/TRSFEROR.
.	YES	NO	DID THE ENTERPRISE QUIRE 5% OR MORE OF	ANY CLASS OF THE PA ASSETS OF OTHER ENTERPRISE? SEE THE CLOF S
			LISTED BELOW.
.	YES	NO	DID THE ENTERPRISE QUIRE 5% OR MORE OF THE	TOTALASSETS OF OTHER ENTERPRISE?
IF THE SWER TO EITHER QUESTION IS YES PROVIDE THE FOLLOWING INFO RMTION UT THE					SELLER/TRANSFEROR

. SELLER/TRSFEROR N					4. FEDER EIN

5. SELLER/TRSFEROR STREETDRESS

CITY/TOWN

STTE	ZIP CODE + 4

6. DTE S QUIRED	. S QUIRED:
	COUNTS RECEIVE	EQUIPMENT	INVENTORY	ND/OR GOODWILL
	CONTRTS	FIXTURES	LE	RE ESTTE
	CUSTOMERS/CLIENTS	FURNITURE	MHINERY	OTHER

IMPORTANT: IF, IN ADDITION TO ACQUIRING ASSETS IN BULK, THE ENTERPRISE ALSO ACQUIRED ALL OR PART OF A PREDECESSOR'S BUSINESS, SECTION 14 MUST BE COMPLETED.

IF THE ENTERPRISE IS ACQUIRING 51% OR MORE OF ANY CLASS OF PA ASSETS AND/OR 51% OF THE TOTAL ASSETS OF ANOTHER ENTERPRISE THE SELLER MUST OBTAIN A BULK SALE CLEARANCE CERTIFICATE. REFER TO INSTRUCTIONS ON PAGE 22.

PA-100 (03-09)		DEPRTMENT USE ONLY
		DEPRTMENT USE ONLY
ENTERPRISE N

SECTION 11 – CORPORATION INFORMATION

. DTE OF INCORPORTION	.	STTE OF INCORPORTION	. CERTIFIC	TE OF THORITY DTE
			ONCORP.

4. COUNTRY OF INCORPORTION

5.	YES	NO	IS THIS CORPORTION'S STOCK PUBLICLY TRED?
6.	CHECK THE OPRITE BOX TO DESCRIBE THIS CORPORTION:
	CORPORTION:	STOCK	PROFESSION	BK:	STTE	MUTU	THRIFT: STTE	INSURCE	P
		NONOCK	COOPERTIVE		FEDER		FEDER	COMPNY:	NON
		MEMENT	STTUTORY CLOSE
. S CORPORTION:		FEDER	INCORDCE WITHT NO.6 OF 6 CORPORTION WITH				FEDER SUBHER S STTUS IS CONSIDERED PS COR
			PORTION. IN ORDER	NOT TO BE T P S CORPORTION REV6			MUST BE FILED. THE FORM C BE CESSED T
			WWWREVENUESTATEPAUS FORMS D PUBLICTIONS CORPORTION T

COMPLETING THIS FORM WILL NOT FULFILL THE REQUIREMENT TO REGISTER FOR CORPORATE TAXES REGISTERING CORPORATIONS MUST CONTACT THE PA DEPART- MENT OF STATE TO SECURE CORPORATE NAME CLEARANCE AND REGISTER FOR CORPORATION TAX PURPOSES CONTACT THE PA DEPARTMENT OF STATE AT (717) 787- 1057, OR VISIT wwwaoeforbusiessstateaus

SECTION 12 – REPORTING & PAYMENT METHODS

. THE DEPRTMENT OF REVENUE REQUIRES THTY ENTERPRISEMNG PYMENTS EQ	U TO OR GRETER TH $ REMIT PYMENTS VI ONE	OF THE FOL
LOWING ELECTRONIC METHODS: ELECTRONIC FUNDS TRSFER T ELECTRO	NIC TINFORMTION D DTEXCHGE SYSTEM IDES TELEFILE SYSTEM OR
CREDIT CD. ENTERPRISE REGDLESS OF UNTIS ENCOURED TO REMIT	TPYMENTS ELECTRONICLY.

a. YES
b. YES
. YES

NO	DOES THIS ENTERPRISE MEET THE DEPRTMENT OF REVENUEʼS REQUIREMENTS FOR ELECT RONIC PYMENTS?
NO	DOES THIS ENTERPRISE WNT TO PRTICIPTE IN THE DEPRTMENT OF	REVENUEʼS ELECTRONIC PROGR
NO	IF THIS ENTERPRISE IS NONOFIT ORGIZTION THT IS EXEMPT UN	DER IRC 5 OR POLITIC SUBIVISIONS IS IT
	INTERESTED IN RECEIVING INFORMTION UT THE DEPRTMENT OF LR &	INDUSTRYʼS OPTION OF FINCING UC COSTS
	UNDER THE REIMBURSEMENT METHOD IN LIEU OF THE CONTRIBUTORY METHOD? FOR MORE DETILS REFER TO SECTION
	INSTRUCTIONS.

THE DEPRTMENT OF LR & INDUSTRY REQUIRES THTY ENTERPRISE WITH		5 OR MORE WGE ENTRIES PER QUTERLY REPORTFILE THE W		GE INFORMTION VI
MNETIC MEDIY MNETIC REPORTING FILE MUST BE SUBMITTED FOR COMPTI		BILITY WITH THE DEPRTMENT OF LR & INDUSTRYʼS FORMT. CONTT			THE M
NETIC MEDI REPORTING UNITT FOR MORE INFORMT	ION.
THE COMMONWETH STRONGLY RECOMMENDS THT ENTERPRISES USE ELECTRONIC FIL			ING D PYMENT OPTIONS FOR CERTN PENNSYLVNI TD SERVICES.
INFORMTION UT INTERNET FILING OPTIONS C BE FOUND ON THE	eIDES WEB SITET		wwwetidesstateaus

SECTION 13 – GOVERNMENT STRUCTURE

. IS THE ENTERPRISE
GOVERNMENT BODY	GOVERNMENT OWNED ENTERPRISE		GOVERNMENT & PRIVTE SECTOR
			OWNED ENTERPRISE
. IS THE GOVERNMENT:
DOMESTIC/US	FOREIGN/NONS		MULTITION
. IF DOMESTIC IS THE GOVERNMENT:
FEDER	LOC:	COUNTY	BOROUGH
STTE GOVERNOR'S JURISDICTION		CITY	SCHOOL DISTRICT
STTE NONOVERNOR'S JURISDICTION		TOWN	OTHER
		TOWNSHIP

Question	Answer
Form Name	Pennsylvania Form Pa 100
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	registration of an enterprise, registration from for entrepise, pennsylvania enterprise registration form pa 100, pa enterprise registration form

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