Earned Income Tax (EIT) and Occupational Privilege Tax (OPT) Withholding Registration Form

*Company Name:

*Company Contact:

*EIN #:

*Address 1:

Address 2:

*City:

*State:

*Zip Code:

*Telephone:

Fax:

Email:

Best time to
contact me:

How will data be
supplied?:

Questions/
Comments/
Notes: