Master License Service Department of Licensing PO Box 9034 Olympia WA 98507-9034 Telephone: (360) 664-1400 www.dol.wa.gov Legal Entity/Owner Name Unified Business Identifier (UBI) Federal Employer Identification Number (FEIN) Information provided may be subject to disclosure under the public disclosure law (RCW 42.56) For Validation - Office Use Only Master Business Application For faster service - Apply online @ www.dol.wa.gov or print in dark ink and mail to Master License Service 01P-400-925-0003 1. Purpose of Application Please check all boxes that apply. Open/Reopen Business Add License/Registration to Existing Location complete sections 2, 3, 4, (5 if hiring employees) and 6 complete sections 2, 3, 4, and 6 Open Additional Location Hire Employees complete sections 2, 3, 4, (5 if hiring employees) and 6 complete all sections Change Ownership Hire Employees Under Age 18 complete sections 2, 3, 4, (5 if you have employees) and 6 complete all sections Register Trade Name Hire Persons to Work In or Around Your Home complete sections 2, 3, 4 and 6 complete all sections Change Trade Name - complete sections 2, 3, 4 and 6 Other - complete all sections Indicate name to be cancelled: Change Location - complete sections 2, 3, 4 and 6 Indicate old address to be closed: 2. Licenses and Fees Use the License Fee Sheet for the information needed to complete this list. Indicate Registrations Needed: Tax Registration – Do you want a separate tax return for each business? Yes No Industrial Insurance (Workers’ Compensation) – Required if you will have employees. Unemployment Insurance – Required if you will have employees. Minor Work Permit – Required if you will have employees under age 18. Fees Due No Fee No Fee No Fee No Fee $ 5.00 New Trade Name (Doing Business As): Indicate Additional Trade Names ($5 each name) or Other Licenses (such as Lottery Retailer): $ $ $ $ Enclose check for total amount due, including the Processing Fee, which MUST be submitted with this form. Make check payable to the WASHINGTON STATE TREASURER. BLS-700-028 (R/010/06) OR/W Page 1 of 4 Processing Fee Total Amount Due $ $ $ 15.00 $ If you need assistance through the telecommunications device for the deaf, please call TTY (360)664-8885. To request this document in an alternate format for the visually impaired, call (360)664-1400. American LegalNet, Inc. www.FormsWorkflow.com a. Select only one ownership structure: Sole Proprietor If married, should spouse’s name appear on license? Yes No (If you answer No, you must still enter the spouse information in section “3f” below.) Corporation* Non Profit Corporation* (educational, religious, charitable) Limited Liability Company* Partnership (# of partners: ) Limited Partnership* Limited Liability Partnership* Joint Venture *These ownership structures must contact the Secretary of State office for additional filing requirements. Name of Corporation, LLC, Partnership, LLP, or Joint Venture Name (examples: ABC, Inc. OR Fir Trees Unlimited LLC) State incorporated/formed: Association Other Partnership / Corporation Sole Proprietor 3. Owner Information Year incorporated/formed: Trust Municipality Tribal Government Other Name of Organization (example: Anderson Family Trust) b. c. d. Indicate this ownership structure’s first date of business at this location. Out-of-state businesses should use the first date of operation in WA. Business Mailing Address (Street & Suite No. or PO Box, do not use building name) ) ( Business Telephone Number City State Zip ) Fax Number Internet/E-Mail Address List all owners & spouses: Sole proprietor, partners, officers, or LLC members. (Attach additional pages if needed.) / Name (Last, First, Middle) Date of Birth Home Address (Street or PO Box) / City ( Title ) Are you married? Yes / / / / Name (Last, First, Middle) Date of Birth Home Address (Street or PO Box) No If yes, enter spouse information below. Spouse Social Security Number Title ) % Owned Social Security Number City ( State Are you married? Yes Zip No If yes, enter spouse information below. Home Telephone Number / / / / Spouse Name (Last, First, Middle) Name (Last, First, Middle) Date of Birth Home Address (Street or PO Box) Spouse Social Security Number Spouse Date of Birth City ( ) % Owned Social Security Number State Are you married? Yes Zip No If yes, enter spouse information below. Home Telephone Number / Spouse Name (Last, First, Middle) Zip Home Telephone Number Spouse Date of Birth Title % Owned Social Security Number State Spouse Name (Last, First, Middle) Governing Persons (Required. If unknown, please estimate.) YY Doing Business As (DBA)/Trade Name e. ( f. / MM / Spouse Date of Birth Spouse Social Security Number The Social Security Number is required for all sole proprietors (RCW 26.23.150) and for all owners and spouses of a business that will have liquor, lottery or private investigator licenses. Not providing this information will result in application delays. BLS-700-028 (R/10/06) OR/W Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 4. Location / Business Information Check the appropriate box and provide the corresponding physical address on line “a” below. This application is for a Washington location (provide the Washington address) Is this Location inside city limits? Yes No This Business has No Washington location (provide the primary business address) a. Business Street Address (Do not use a PO Box or PMB Address) City State Zip If the address above is out-of-state and you have employees or representatives working in Washington, please provide one of their Washington addresses (we will not use this address for mailing purposes): Street Address (Do not use a PO Box or PMB Address) b. State Zip Provide the estimated gross annual income in Washington (check the one box that applies to your business): $0 - $12,000 c. City $12,001 - $28,000 $28,001 - $60,000 $60,001 - $100,000 Indicate the business activities in Washington State (check all that apply): Wholesale Retail Manufacturing $100,001 and above Services d. Describe in detail the principal products or services you provide in Washington State (failure to provide this information will cause delay in processing your application): e. Did you buy, lease, or acquire all or part of an existing business? / Date bought/leased/acquired: MM No All Part / DD YY Prior Business Name ( Prior Owner’s Name f. ) Telephone Number Did you purchase/lease any fixtures or equipment on which you have not paid sales or use tax? If yes, indicate purchase or lease price: Yes No $ g. If this business is owned by, controlled by, or affiliated with any other business entity, please indicate that business entity’s name: h. If you are changing your business structure (such as changing from sole proprietorship to corporation) and want the old account closed, please indicate the UBI number to be closed: Do you wish to cancel all the trade names registered under the old UBI number? Yes No (You must re-register all trade names you use under the new business structure.) i. If you have ever owned another business, please provide: Business Name j. Provide your bank’s name: UBI Number Branch: If you plan to have employees or wish to register for elective coverage for owners or excluded employees, complete Section 5. (For information see the Industrial Insurance or Unemployment Insurance sections on the License Fee Sheet.) BLS-700-028 (R/10/06) OR/W Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com 5. Employment / Elective Coverage Employment accounts cannot be established unless you plan to employ persons within the next 90 days. If accounts are established, employment tax returns will be required quarterly even if you have not hired. a. Date of first employment or planned employment at this location: / / First date wages paid: / / MM DD YY MM DD b. Number of persons you employ or plan to employ at this location (do not include owners): c. Estimate the number of persons under age 18 (minors) you will employ in the next 12 months and duties they will perform: Number YY Duties to be performed by minors (Check www.teenworkers.lni.wa.gov) Ages 16-17: Ages 14-15: Under age 14: d. Please check the ONE box which best describes the major operation of your business. (01) Construction-Wood Framing only (02) Construction - All other (03) Logging/Forestry/Trucking (04) Temp. Help/Employee Leasing (05) Shipbuilding (06) Mining/Quarrying/Sand & Gravel (07) Mfg. - Wood/Metal/Stone Products (08) Mfg. - Chemicals (09) Mfg. - Food Products (10) Miscellaneous Mfg. (11) Machine Shops/Auto Repair (12) Agricultural/Farming e. Describe in detail the activities of your workers. Then estimate the total workers’ hours for a 3-month period. (One full-time worker = 480 total hours for 3 months.) Example: (13) Retail/Wholesale Trade (14) Services/Maint./Restaurants (15) Communications (16) Clerical/Professional Occup. 3-Month Estimate Number of Workers’ Hours Workers (Include Minors) 2 Office Staff - reception, accounting, data entry 960 f. If you have more than one Washington location, how do you wish to receive the following quarterly reports? Unemployment Insurance: Workers’ Compensation: All locations combined All locations combined Each location separately (multiple reports) Each location separately (multiple reports) Elective Coverage is available as noted below. (See License Fee Sheet for more information.) g. Do you want unemployment insurance coverage for corporate officers? (Only available for corporations.) Yes – Prior to coverage, Form 5203 is required. This form will be sent to you by Employment Security Dept. No – The corporation must inform officers in writing that they are not covered for unemployment insurance. h. Do you want workers’ compensation coverage for owners (sole proprietor, partners, corporate officers, LLC members/ managers)? (In an LLC with managers, you may elect to cover those persons who are both members (owners) and managers. In an LLC with members only, you may elect to cover those members.) Yes – Prior to coverage, Form F213-042-000 is required. This form will be sent to you by the Dept. of Labor & Industries. No i. Do you want elective workers’ compensation coverage for excluded employment? (See License Fee Sheet for descriptions.) Yes – Prior to coverage, Form F213-112-000 is required. This form will be sent to you by the Dept. of Labor & Industries. No 6. Signature Signature of sole proprietor or spouse, partner, corporate officer, or limited liability member/manager. I, the undersigned, declare under the penalties of perjury and/or the revocation of any license granted, that I am the applicant or authorized representative of the firm making this application and that the answers contained, including any accompanying information, have been examined by me and that the matters and things set forth are true, correct and complete. X / Signature Required ( Application Prepared By (Please Print) Title BLS-700-028 (R/10/06) OR/W Page 4 of 4 ) / Telephone No. ( UBI Agency Representative / Date ) Telephone No. / Date / / Date American LegalNet, Inc. www.FormsWorkflow.com