Print Review IRS Form SS-4 BIN
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Form SS"4
(Rev December 300!) Department of the
Treasury
Intern^ Revenue Service
Application for Employer Identification Number
(For use by employers, corporations, partnerships, (rusts, estates, churches, government agencies, Indian tribal entitles, certain Individuals, and others}
* See separate Instructions for each line. Keep a copy for your records
EIN
20-5200242 OMB No, 1545-0003
1* Legal name of entity (or individual} for whom the EIN is being requested National Affiance ol Painttess Dent Repair Technicians
2 Trade name of business (if different from name on line 1)
3* Executor, trustee, "care or name Jamie Hawkins
4a* Mailing address (room, apt. suite no. and street, or P 0 box)
5903 Moravia Road______
4b" City, state, and ZIP code Winston Salem NC 27127-
5a Street address (If different) (Do not enter a P 0 box)
5b City, state, and ZIP code
6* County and state where principal business is located
County ForsyttiL State NC______
7a Name of principal officer, general partner, grantor, owner, or truslor
7bSSN.ITIN.EIN
8a* Type of entity (check only one) r. Sole Proprietor (SSN)
f~ Partnership
r~ Corporation (enter form number to be filed)
!~ Personal Service
H Church or church-controlled organization
f? Other nonprofit organization (specify) * business league
r other (specify) >•______
8b If a corporation, name the state or foreign country (if applicable) where incorporated
State NC
restate (SSN of decedent)
r plan administrator {SSN)
f~ Trust (SSN of grantor)
r National Guard
f~ Fanners' cooperative
fjREMIC
Group Exemption NO (GEN) i
f~ State/local government I~ Federal government/military
Foreign country
9' Reason for applying (check only one)
I? Started new business (specify type)
business league
r~ Hired employees (Check the box and see line 12)
r Diner (specify) »
10* Date business started or acquired (month, day, year) JUL 6 2006
~ Banking purpose (specify purpose) *
f~ Changed type of organization (specify new type)
f** Purchased going business
r created a trust (specify type) *•
r Created a pension plan (specify type)
11 Closing month of accounting year
12 First date wages or annuities were paid or will be paid (month, day, year) fVofe.tf eppfcart is a withholding agent, enter date
Income will fast be paid to nonresident alien, (month, day, ye»)______*•
13
does not expect to have any employees during the period, enter'-!)•'
14' Check box that best describes the principal activity of your business
f~ Construction F~ Rental & leasing l"~ Transportation & ware
l~ Real estate I~" Manufacturingf~ Finance & insurance
(?. Ulhef(8pecJty) business league
Household 0
Other 0
Agriculture 0
I Health care & social assistance I Whotesale-agenUbroker r* Accommodation & food service i~ Wholesale-other
15* Indicate principal line of merchandise sold; specific construction work done; products produced; or services provided
discuss indstry trends- educallon-fltp health ins
16s* Has Die applicant ever applied for an employer identification number for this or any other business?.
Hole ff •Yes" flfease complete ft»s 16* ant J6c______
16b If you checked "Yes* on line 1 Sa, give applicant's legal name and trade name shown on prior application if different from line 1 or 2 above
legs! name *
Trade name *______
16c Approximate date when, and city and stale where, the application was filed Enter previous employer identification number If known
Approximate date when filed (month, day, year) I City and state where tiedI Previous EIN
Complete section only if you want to aulhorfee ins named individual to ref*ve8»«»l%^ EIN am) answefquesSeas about Biecontptetootftisfbim
Third Party
Designee
Deskjnee'sname Cyndl Freeman Address and ZIP code
155 Sunnvnoll Court Winston Salem NCJ7106 -
Deagnee's tetoplxme number (tnctodt ataa code)
(336) 71f - 5771
assignee's lax number (factute ana code)
( 336 ) 724 - 1228
Under penalties «f |»jwy.l declare that I (we examined this application. end to the best of my knowtedse and ta8ef.lt Is h».
correct and contptelB
Name and title (type or print clearly)
Apptanrsteisphoneraimbaftindudeamacode)
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7/14/2006