New Business Request Form

Type of business applying for?*

Desired IRS Tax Treatment?*

Proposed Business Name #1*

Proposed Business Name #2*

Proposed Business Name #3*

Business phone number*

Please enter a valid phone number.

Website address

Organization's email

example@example.com

If business established, what is the name of the entity?

Is your business foreign entity or domestic?

Business address (if home based business, leave blank)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Authorized Business Contact Information

First NameLast Name

Authorized Business Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What if your business or non-profit structure?

State incorporated or planning to incorporate?

If formed, date of formation.

Date

What is your business's industry?

What is your business EIN#

xx-xxxxxxx or None

Description of your business

Does your business require Industrial Insurance?

YesNoNot Sure

Does your business require Professional Occupation License?

YesNoNot sure

Professional License description and number associated with it.

Is your business currently operating?

YesNo

Have you registered your business with the Secretary of State?

YesNo

Nevada State License Number?

Does your business require accounting services?

YesNo

What is your AGI (annual Gross Income)

0-50,00050,000-100,00100,000-500,000500,000 and above

Non Profit Questionnaire

(IF THIS DOES NOT APPLY SKIP THIS SECTION AND SELECT NEXT ON THE BOTTOM OF THE APPLICATION)

If Non Profit 501(c)3, what will your non-profit operate as?

Will your Non Profit pay compensation to any officers, directors, or trustees?

Yes or No

Will your Non-Profit Attempt to Influence Legislation?

Yes or No

Will your Non Profit donate funds to pay expenses for individuals?

Yes or No

Do you or will you conduct activities or provide grants or other assistance to individual(s) or organization(s) outside the United States?

Yes or No

Do you or will you have unrelated business gross income of $1,000 or more during a tax year?

Ys or No

Do you or will you engage in financial transactions (for example, loans, payments, rents, etc.) with any of your officers, directors, or trustees, or any entities they own or control?

Yes or No

Do you or will you operate bingo or other gaming activities?

Yes or No

Do you or will you provide disaster relief?

Are you applying for recognition as a church, school, or hospital (described in section 170(b)(1)(A)(i), (ii), or (iii) of the Internal Revenue Code)? If yes, stop. Do not file Form 1023-EZ.

Yes or No

See Instructions to attest that you normally receive at least one-third of your support from public sources or you normally receive at least 10 percent of your support from public sources and you have other characteristics of a publicly supported organization. Sections 509(a)(1) and 170(b)(1 )(A)(vi) to attest that you normally receive more than one-third of your support from a combination of gifts, grants, contributions, membership fees, and gross receipts (from permitted sources) from activities related to your exempt functions and normally receive not more than one-third of your support from investment income and unrelated business taxable income. Section 509(a)(2) to attest that you are operated for the benefit of a college or university that is owned or operated by a governmental unit. Sections 509(a)(1) and 170(b)(1 )(A)(iv) to attest that your organizing document contains the provisions required by section 508(e) or that your organizing document does not need to include the provisions required by section 508(e) because you rely on the operation of state law in your particular state to meet the requirements of section 508(e). (See the instructions for explanation of the section 508(e) requirements if you are seeking retroactive reinstatement under section 4 of Revenue Procedure 2014-11. By checking this box, you attest that you meet the specified requirements of section 4, that your failure to file was not intentional, and that you have put in place procedures to file required returns or notices in the future. (See the instructions for requirements.) if you are seeking reinstatement under section 7 of Revenue Procedure 2014-11, effective the date you are filing this application.

Type of Business or Charity Services Offered

I declare under the penalties of perjury that I am authorized to sign this application on behalf of the above organization and that I have examined this application, and to the best of my knowledge it is true, correct, and complete.*

New Business Request Form

Member's Information

Business Information