Master Application License Service (Washington)
This form is an application for license service. The form provided here is simply a sample of what the actual Form 700-028 looks like.
Master License Service
Department of Licensing
P O Box 9034
Olympia WA 98507-9034
Telephone: (360) 664-1400
www.wa.gov/dol
Information provided may be subject to disclosure under the public disclosure law (RCW 42.17)
MASTER APPLICATION
(Please type or print clearly in dark ink.)
Mail Directly to the Master License Service or file in person at any UBI service location.
Owner Name ___________________________________
Unified Business Identifier (UBI) ___________________________________
Federal Employer Identification Number (FEIN) ___________________________________
For Validation - Office Use Only
01P-400-731-0003
1. Purpose of Application
Please check all boxes that apply
____ Open/Reopen Business complete sections 2, 3, (4 if hiring employees) and 5
____ Hire Employees complete all sections
____ Change Ownership complete sections 2, 3, (4 if you have employees) and 5
____ Hire Employees Under Age 18 complete all sections
____ Add License/Registration to Existing Location complete sections 2, 3 and 5
____ Hire Persons to Work in or Around Your Home complete sections 2, 3c, 4 and 5 (no application fee)
____ Register Trade Name complete sections 2, 3 and 5
____ Change Trade Name - complete sections 2, 3 and 5 indicate name to be canceled: _______________________________
____ Change or Open Location - complete sections 2, 3a, 3b, 3c and 5 indicate old address to be closed: _______________________________
____ Other ___________________________________ complete all sections
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/trade name? ____ Yes ____ No, No Fee
____ Industrial Insurance (if you will have employees) No Fee
____ Unemployment Insurance (if you will have employees) No Fee
____ Minor Work Permit (if you will have employees under age 18) No Fee
____ New Trade Name (Doing Business As): _______________________, $ 5.00
Indicate Other Licenses (such as Lottery Retailer) or additional Trade Names ($5 each name):
(see License Fee Sheet for more information.)
__________________________ $____________
__________________________ $____________
__________________________ $____________
__________________________ $____________
Application Fee $ 15.00
Total Amount Due $____________
Enclose check for total amount due, including the Application Fee, which MUST be submitted with this form
Make check payable to the WASHINGTON STATE TREASURER.
If you need assistance through the telecommunications device for the deaf, please call TTY (360)586-2788.
3. Business Information
Please check the one box that applies to your business:
Business Open Date ____________ If unknown, please estimate
a. Please complete the appropriate section for business ownership structure. Attach additional sheets if necessary
____ Sole Proprietor: Should spouse's name appear on license? ____ Yes ____ No (if applicable)
____ Partnership
____ Limited Partnership
____ Limited Liability Partnership
____ Limited Liability Company
____ Washington Corporation
____ Out of State Corporation
____ Non Profit Corporation (educational, religious, charitable)
____________________________________________ Partnership, Corporation, LLC or LLP Name
State incorporated/formed: _______________________________
Year incorporated/formed: _______________________________
-----------------------------------------
____ Association
____ Trust
____ Municipality
____ Other _______________________________
_______________________________ Name of Organization
b. Doing Business As (DBA)/Trade Name _______________________________
County in Which Business is Located _______________________________
Inside city limits? ____ Yes ____ No
Business Mailing Address (Street or PO Box, Suite No. Do not use building name)
_______________________________
City _______________________________
State _______________________________
Zip _______________________________
Business Street Address in Washington (if different than mailing address)
_______________________________
City _______________________________
State _______________________________
Zip _______________________________
Business Telephone Number _______________________________
Fax Number _______________________________
Internet/E-Mail Address _______________________________
List all owners: Sole proprietor, partners, officers, and LLC members. Attach additional pages if needed.
_______________________________ Name (Last, First, Middle)
_______________________________ Title
_______________________________ Home Address (Street or PO Box)
_______________________________ City
_______________________________ State
_______________________________ Zip
_______________________________ Home Telephone Number
_______________________________ Date of Birth
_______________________________ Social Security Number
_______________________________ % Owned
_______________________________ Spouse's Name (Last, First, Middle)
_______________________________ Date of Birth
_______________________________ Social Security Number
_______________________________ Name (Last, First, Middle)
_______________________________ Title
_______________________________ Home Address (Street or PO Box)
_______________________________ City
_______________________________ State
_______________________________ Zip
_______________________________ Home Telephone Number
_______________________________ Date of Birth
_______________________________ Social Security Number
_______________________________ % Owned
_______________________________ Spouse's Name (Last, First, Middle)
_______________________________ Date of Birth
_______________________________ Social Security Number
Social Security Number is required for all sole proprietors (RCW 26.23.150) and for all persons associated with a business that will have liquor, lottery, or private investigator licenses, in accordance with the Washington laws regulating those businesses.
d. Estimated Gross Annual Income in Washington
Please check one box that applies to your business:
____ 0 - $12,000
____ $12,001 - $28,000
____ $28,001 - $60,000
____ $60,001 - $100,000
____ $100,001 and above
e. Please indicate which of these business activities you do in Washington State (check all that apply):
____ Wholesale
____ Retail
____ Manufacturing
____ Services
f. 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). ___________________________
g. Did you buy, lease, or acquire all or part of an existing business? ____ No ____ All ____ Part
Date bought/leased/acquired: __________/___________/___________
___________________________ Prior Business Name
___________________________ Prior Owner's Name
h. Did you purchase/lease any fixtures or equipment on which you have not paid sales or use tax? ____ Yes ____ No
If yes, indicate purchase or lease price: $________________
i. If this business is owned by, controlled by, or affiliated with any other business entity, please indicate that business entity's name: ___________________________
If NO, skip to section 5.
If YES, complete sections 4 and 5.
j. 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: ___________________________
k. If you have ever owned another business, please provide: ___________________________
l. List your bank's name: ___________________________
Business Name UBI Number
Do you plan to have employees or wish to register for optional coverage? (Some LLC members are considered to be employees . For further information on optional coverage definitions, see License Fee Sheet)
____ Yes ____ No
If NO, skip to section 5.
If YES, complete sections 4 and 5.
4. Employment
Complete if you employ, or plan to employ, one or more persons in Washington State; or if you want optional coverage under this ownership
a. Date of first employment or planned employment at this location: ______/______/______
First date wages paid: ______/______/______
b. Number of persons you employ or plan to employ at this location (Do not include owners): ___________________________
c. Estimate the number of persons under 18 (minors) you will employ in the next 12 months: ___________________________
• Estimate the number of minors that will be under 16: ___________________________
• Are any of the minors working in an agricultural business? ____ Yes ____ No
• List the specific duties performed by minors at this location: ___________________________
d. If you operate at more than one location, do you wish to report the employee information at the locations:
____ Together ____ Separately
e. Do you want unemployment insurance coverage for corporate officers?
____ 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.
f. Do you want industrial insurance coverage for sole proprietor(s), partners, owners, corporate officers, or LLC members?
____ Yes - Prior to coverage, Form F213-042-000 is required. This form will be sent to you by the Department of Labor and Industries.
g. Do you want optional industrial insurance 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 and Industries.
h. If your entity is a Limited Liability Company, is your management vested?
____ Yes - If managers are also members, they are exempt from industrial insurance coverage
____ No - If managers are not members, they are mandatorily covered for industrial insurance coverage.
i. Please check the ONE box which best describes the major operation of your business and provide activity in detail below.
____ (01) Construction-Wood Frame Bldg.
____ (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
____ (13) Retail/Wholesale Trade
____ (14) Services/Maint./Restaurants
____ (15) Communications
____ (16) Clerical/Professional Occup.
j. Describe in detail the activities of your employees and/or indicate the category of optional coverage for excluded employment requested.
3-Month Estimate
______________________________________________
Number of Employees ____________ Workers' Hours (Include Minors) ____________
______________________________________________
Number of Employees ____________ Workers' Hours (Include Minors) ____________
5. 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
_____________________________ Date
______________________________________________ Application Prepared By (Please Print) Title
______________________________________________ Telephone No.
______________________________________________ Date
______________________________________________ UBI Agency Representative
______________________________________________ Telephone No.
______________________________________________ Date