NJ-REG-A (Rev 12/06) Business Registration and Certification for Individuals Contracting with Public Agencies and for Unincorporated Construction Contractors OFFICIAL USE ONLY DLN#: Ch. 57, P.L. 2004: State law requires all contractors and subcontractors with the State or other public sector entities to provide proof of registration with the Department of Treasury. Chapter 85, P.L. 2006, defined under N.J.S.A. 54A:7-1.2: You must use this form to comply with the law if you are an unincorporated construction contractor performing services in NJ and need proof of registration from the Division of Revenue. You may use this form to comply with the above-referenced laws if you are an individual with no business tax or employer obligations with the State of New Jersey and are not yet registered. Fill out the registration section and certification below and send the completed form to: NJ Division of Revenue Client Registration Bureau PO Box 252 Trenton, NJ 08646-0252 Please note that the registrant's name listed in Section A must be the same as shown in the Certification, Section B. Type, machine print or hand print all information, except your signature. If you have or will have business tax or employer obligations, file form NJ-REG. Call (609) 292-1730 for more information. If you currently are registered, please enter your NJ Taxpayer Identification Number in the space provided below. SECTION A. REGISTRATION DETAIL Social Security Number Registrant's Name Physical Address: Street, City, State, Zip Do not use P.O Box County Mailing Address: Street, City, State, Zip Contact Information: Telephone Number E-mail Address SECTION B. CERTIFICATION I __________________________________________ hereby certify that I am an individual having no business tax or employer obligations with the State of New Jersey. Further, I certify that any income that I derive from business activities with the State of New Jersey will be reported on my personal income tax return. I understand that pursuant to State law, if I knowingly report inaccurate of misleading information, I maybe subject to penalties. Signed: ________________________________ Date: _______________ Signature Title: ______________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com