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Utah State Tax Commission

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Application for Representative License Renewal / New Application

TC-760
Rev. 7/09

FEE: $26 Representative
First name Home address Home telephone number (include area code) Middle name Last name City Social Security Number License number State Date of birth ZIP Code

Under state and federal law we cannot issue a license to any person who does not provide the following residency information:

Check one: I am a U.S. citizen. SSN: ________________ I qualify under 8 U.S.C. 1641 and I am present in the U.S. lawfully. I-94# or SSN: ________________ Alien #: ________________
The Alien Registration Number (A#) and the I-94 (arrival/departure) number are issued by the U.S. Citizenship and Immigration Service.

I hereby apply for a new/renewal Representative License for the year July 1, _____ through June 30, _____ . _ I do solemnly swear (or affirm) that the above statements are true and correct.

Form must be signed before submitting. ____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____________
Signature of applicant

___________________
Date

Employer
Business name Business owner's name (PRINT) Position License number

The above applicant is currently employed by this firm, and I certify that the information on this application is true and correct to the best of my knowledge and belief. I recommend the applicant to be licensed as a representative of the State of Utah.

Form must be signed before submitting. ____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____________
Signature of owner

___________________
Date

IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.

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