Company Information Questionnaire
Use Alt-File-Print to get a copy of this Company Information Questionnaire for use in starting or maintaining a company.
If you would like to decide most of the answers the various governmental agencies will need to know for a new company before they ask, so you can plan the structure of a new company, you will want to print yourself a copy of the following form Growth And Development Services Corporation has put together for your use. We believe that having all the answers to the following questions will bring you pretty close to all the information you will need to keep on hand as you start up your new company or maintain an existing one!!
COMPANY STARTUP INFORMATION
Corporation ____ LLC ______
Name ___________________________________________________
Address _________________________________________________
City ____________________________________________________
State ___________________________________________________
Zip _____________________________________________________
County __________________________________________________
Your Date Of Birth ______________________________________
Social Security Number __________________________________
Phone No. _______________________________________________
Fax No. _______________________________________________
Company Name ________________________________________
Company Address _____________________________________
Mailing Address _______________________________________
Federal Tax Identification Number _____________________
Business Telephone ____________________________________
Location(s)Of Business Operations _______________________________________________________ _______________________________________________________
Location Of Business Records ___________________________
Location Where Local Business License Is Displayed _________________________________________________________
Is Your Business Located In Shopping Center ___Yes ___ No
If Yes, Provide The Name _______________________________
Business Name __________________________________________
Fax No._________________________________________________
Preliminary Telephone No. To Contact For Inspections _________________________________________________________
Industrial Waste:_______________________________________
Will The Operations Of This Business, The Unincorporated Area Of Clark County, Be Consistent With The Operating Standards Of Your Industry ___ Yes ___ No
Please Explain In Detail. _______________________________ _________________________________________________________
Where Will The Merchandise And/Or Your Equipment Be Stored _________________________________________________________
List The Storage Address Of Vehicles Used By Business:________________________________________________
If Business Purchased, Was It In Compliance With NRS104, Uniform Commercial Code ___ Yes ___ No
State License No: _______________________________________
Sales/Use Tax Permit No: ________________________________
Clark County Health Permit No: _________________________
Other __________________________________________________
Seating Capacity(If Restaurant) ________________________
Type Of Entity: Check ___ Sole Proprietor ___ Sub-Chapter S Corp. ___ Association ___ Partnership ___ Limited Liability ___ Publicly Traded Corporation ___ Privately-Held Corporation ___ Other ___________________
Name Of Resident Agent _________________________________
Address Of Resident Agent ______________________________
City Of Resident Agent _________________________________
State Of Resident Agent ________________________________
Zip Of Resident Agent __________________________________
Phone Of Resident Agent ________________________________
Fax Of Resident Agent __________________________________
Name Of Bank ____________________________________________
Address Of Bank _________________________________________
City Of Bank ____________________________________________
State Of Bank ___________________________________________
Zip Of Bank _____________________________________________
Phone Of Bank ___________________________________________
Fax Of Bank ____________________________________________
Name Of Council __________________________________________
Address Of Council ______________________________________
City Of Council __________________________________________
State Of Council _________________________________________
Zip Of Council ___________________________________________
Phone Of Council _________________________________________
Fax Of Council ___________________________________________
Annual Meeting Day or Date (i.e. the first Friday in March): _________________________________________________
ANNUAL MEETING DAY OR DATE: Annual Meeting. The annual meeting of the owners of this company shall be held on the First Friday in March of each year or at such other time and place designated by the Board of Directors of the company.
No. of Shares The Corp. Is Authorized to Issue __________
No. Of Shares With Par Value ___________________________
No. Of Shares Without Par Value ________________________
Governing Board Shall Be Either Directors Or Trustees
Check One _____ Directors _____ Trustees ____ Members
The Purpose Of The Company Shall Be ____________________ ________________________________________________________
Initial Managers until the first meeting of owners:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
The First Board Of Directors Shall Consist Of __ Members
1st. Officers Name _____________________________________
1st. Officers Title ____________________________________
1st. Officers Address __________________________________
1st. Officers City _____________________________________
1st. Officers State ____________________________________
1st. Officers County ___________________________________
1st. Officers Zip ______________________________________
1st. Officers S.S.N. ___________________________________
1st. Officers D.O.B. ___________________________________
1st. Officers Phone ____________________________________
1st. Officers Fax ______________________________________
2nd. Officers Name _____________________________________
2nd. Officers Title ____________________________________
2nd. Officers Address __________________________________
2nd. Officers City _____________________________________
2nd. Officers State ____________________________________
2nd. Officer County ____________________________________
2nd. Officers Zip ______________________________________
2nd. Officers S.S.N. ___________________________________
2nd. Officers D.O.B. ___________________________________
2nd. Officers Phone ____________________________________
2nd. Officers Fax ______________________________________
3rd. Officers Name _____________________________________
3rd. Officers Title ____________________________________
3rd. Officers Address __________________________________
3rd. Officers city _____________________________________
3rd. Officers State ____________________________________
3rd. Officers County ___________________________________
3rd. Officers Zip ______________________________________
3rd. Officers S.S.N. ___________________________________
3rd. Officers D.O.B. ___________________________________
3rd Officers Phone _____________________________________
3rd Officers Fax _______________________________________
4th Officers Name ______________________________________
4th. Officers Title ____________________________________
4th Officers City ______________________________________
4th Officers State _____________________________________
4th Officers county ____________________________________
4th Officers Zip _______________________________________
4th Officers S.S.N. ____________________________________
4th Officers D.O.B. ____________________________________
4th Officers Phone _____________________________________
4th Officers Fax _______________________________________
Fictitious Firm Name(D.B.A.)____________________________
Describe The Nature Of Your Business ________________________________________________________ ________________________________________________________
BY-LAW OR OPERATING AGREEMENT INFORMATION
COMPANY DIRECTOR OR MANAGER MEETING FEES: _____________________
MAX. # OF OWNERS: __________________________________________________
RIGHT OF FIRST REFUSAL OPTION DAYS : _______________________________
Each owner shall offer to the company or to other stockholders of the company a 30 day "first refusal" option to purchase owner's share should owner elect to sell owner's share.
SPECIAL MEETING - % OF VOTE REQUIRED TO CALL: ______________________ Special meetings of the owners shall be held when directed by the Managers, President or the Board of Directors, or when requested in writing by the holders of not less than ________ of all the ownership shares entitled to vote at meetings.
SPECIAL MEETING DAYS : ______________________________________________
A meeting requested by owners shall be called for a date not less than (i.e. 10 nor more than 60 days) after the request is made, unless the owners requesting the meeting designate a later date.
WRITTEN NOTICE FOR MEETINGS : ______________________________________ Written notice stating the place, day and hour of the meeting and, in the case of a special meeting, the purpose or purposes for which the meeting is called, shall be delivered not less than (i.e. 10 nor more than 60 days) before the meeting.
QUORUM VOTE : ______________________________________________________ Owner Quorum and Voting. A (i.e. majority) of the shares entitled to vote, represented in person or by proxy, shall constitute a quorum at a meeting of owners.
PROXIES NOT VALID MONTHS: _________________________________________
An owner may vote either in person or by proxy executed in writing by the owner or his duly authorized attorney-in-fact. No proxy shall be valid after the duration of (i.e. 11 months) from the date thereof unless otherwise provided in the proxy.
DIRECTOR’S COMPENSATION AUTHORITY: ______________________________
The (i.e. managers, owners, stockholders, etc.) shall have authority to fix the compensation of directors, managers or voting members.
# NUMBER OF DIRECTORS OR MANAGERS: ______________________________
This company shall have (i.e. 1 to 9 directors, 3 to 7 voting members, managers, etc.)
OWNERS TO REMOVE A DIRECTOR: _____________________________________
At a meeting of owners called expressly for that purpose, any (i.e. director or the entire Board of Directors, or any manager) may be removed, with or without cause, by a vote of the holders of a majority of the votes at an election of directors, or managers..
% OWNERS TO INSPECT: ________________________________________________ Owners' Inspection Rights. Any person who shall have been a holder of record of shares or of voting trust certificates thereof at least six months immediately preceding his demand or shall be the holder of record of, or the holder of record of voting trust certificates for, at least five percent(5%) of the outstanding shares of the company, upon written demand stating the purpose thereof, shall have the right to examine, in person or by agent or attorney, at any reasonable time or times, for any proper purpose its relevant books and records of accounts, minutes and records of owners and to make extracts therefrom.
FIRST ANNUAL DIRECTOR’S MEETING RESOLUTIONS
CAFETERIA PLAN MONTHS: ____________________________________________
All employees of the company will be entitled to participate in the Company Cafeteria Plan provided that they are currently employed and have been employed for the preceding (i.e. three(3) consecutive months) prior to their entering into the plan.
GROUP LEGAL PLAN AMOUNT: ________________________________________
Employees electing to accept benefits in lieu of cash are eligible to participate in the Company Group Legal Services Plan. Under the terms of this plan, the company will make a contribution of up to (i.e. $70.00) per year toward the premiums of a qualified Group Legal Services Plan which will provide legal aid and support for the employee and members of his or her immediate family
DEP/CHILD CARE SERV AMOUNT: ______________________________________
The employer - provided Child or Dependent Care Services offered under � 129 of the Internal Revenue Service Code is restricted to dependent children under the age of 13 and/or a spouse who are mentally or physically incapable of taking care of themselves. The total amount which may be allocated to this benefit may not exceed the lesser of (i.e. $5,000.00) or the total salary or wages of the participant per year.
MEDICAL PLAN MONTHS: ____________________________________________
All employees of the company and their immediate families which are limited to lawful spouse and dependent children under the age of 21 unless enrolled as a full time college student at a state accredited college or university, will be entitled to full reimbursement of all medical and dental expenses provided that they are currently employed and have been employed for the preceding (i.e. three(3) consecutive months) prior to submission of their claim.
PAID MEDICAL LEAVE DAYS: __________________________________________
Such care and treatment includes, but shall not be limited to, medicine, physical therapy, special equipment, prosthetic appliances as well as recuperative paid leave not to exceed (i.e. thirty(30)) calendar days.
EDUCATIONAL REIMBURSEMENT AMOUNT: ____________________________
All qualified employees of the company will be entitled to reimbursement of educational expenses incurred for fees, tuition, books, supplies, equipment, etc. up to the amount of (i.e. $5,250.00) per year for formal courses of study
EDUCATIONAL QUALIFYING MONTHS: _________________________________
Qualified employees include all employees who are currently employed and who have been employed for the preceding (i.e. twelve(12) consecutive months) prior to submission of their claim for educational reimbursement.
INITIAL OWNER'S MEETING
MEETING DATE: ____________________________ TIME: ______________________
LOCATION: ____________________________________________________________
CITY: ________________________________ ST: _________ ZIP _________-_______
INITIAL MANAGER'S MEETING
MEETING DATE: ____________________________ TIME: ______________________
[ ] SAME LOCATION AS INITIAL STOCKHOLDERS MEETING
LOCATION: ____________________________________________________________
CITY: ________________________________ ST: _________ ZIP _________-_______
MEETING CHAIRMAN NAME: ____________________________________________
MEETING SECRETARY NAME: ____________________________________________
PERSONS PRESENT: _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
FIRST ANNUAL OWNER'S MEETING
ANNUAL MEETING NOTICE DATE: ________________________________________
MEETING DATE: _________________________________ TIME: __________________
[ ] SAME LOCATION AS INITIAL OWNERS' MEETING
LOCATION: _____________________________________________________________
CITY: _________________________________ ST: _________ ZIP _________-_______
FIRST ANNUAL MANAGER’S MEETING
FIRST ANNUAL MANAGERS' MEETING NOTICE DATE: _______________________
MEETING DATE: _____________________________ TIME: ______________________
[ ] SAME LOCATION AS INITIAL STOCKHOLDERS MEETING
LOCATION: _____________________________________________________________
CITY: __________________________________ ST: _________ ZIP _________-_______
Please Check All That Apply ___ Mining ___ Service ___ Tobacco ___ Delivery ___ Wholesale ___ Domestics ___ Agriculture ___ Manufacturing ___ Transportation ___ Not For Profit ___ Outside Dining ___ Home Occupation ___ Retail Sales New ___ Retail Sales Used ___ Live Entertainment ___ Water Appropriation ___ Hazardous Material ___ Construction/Erection ___ Telephone Solicitation ___ Environmental Discharge ___ Adult Materials/Activity ___ Amusement Machines ___ Leased Or Leasing Employees ___ Leasing(Other Than Employees) ___ Regulated By Federal/State Permit# _________ ___ Supply/Use Temporary Workers ___ Alcohol ___ Gaming ___ Other _______ __________________________________________________________
Estimated Total Monthly Receipts _________________________
Estimated Monthly Taxable Receipts _______________________
Reporting Cycle (Check one) _____ Monthly ____ Quarterly
Security $100 Minimum/No Maximum Amount ________________
Total Business Locations _______________________________
Sales Tax Fees $________________________________________
Business License Fees $ ________________________________
Date Business Started Or Acquired ______________________
1st. Date Wages Or Annuities Were Or Will Be Paid ______
Highest # of Employees Expected Next in Next 12 mos. ___ [If Not Expected To Have Employees In Period Enter (0)]
Is The Principal Activity Manufacturing ________________
If "yes" The Principal Product And Raw Material Used ________________________________________________________
To Whom Are Most Of The Products Or Services Sold (Check One) ___ Business(Wholesale) ___ Public(Retail) ____ Other(Specify)___________________________________
Has The Applicant Ever Applied For A Business ID. No. Yes ___ No ___
If Yes Please Enter Legal Or Trade Name _______________
Approximate Date Application Was Filed _________________
City Where Application Was Filed _______________________
State Where Application Was Filed ______________________
Address To Which payroll Reports Are To Be Mailed ________________________________________________________
Do Any Of The Owners Of This Business Have An Interest In Any Other Business In the State _____ Yes _____ No
If Yes List The Owners Name ____________________________
The Other Business Name ________________________________
The Percent Of Ownership In That Business ______________
If It Is A Publicly Traded Corporation List Any Subsidiary Accounts Operating In this State ________________________ _________________________________________________________ _________________________________________________________
Provide The Name And Address Of Any Prior Owner Of This Business, If Any ________________________________________
Is The Applicant Under The Protection of The Federal Bankruptcy Court _____ Yes _____ No
If Yes Case No. ________________________________________
Location Of Court ______________________________________
Filed Under Chapter ____________________________________
Date Of Filing _________________________________________
Was Applicant Previously Insured By State ___ Yes ___ NO
If Yes Account No. ____________________________________
If Yes Closure Date ___________________________________
Has This Business, Under The Same Ownership, Operated For Three(3) Or More Years In Another State Immediately Proceeding The Onset Of Its Operations In ____ Yes ____ No
If Yes Please List The State In Which This Business Has Operated ________________________________________________________
If Yes Please List The Period Of Time During Which Those Operations Occurred.
Please List Your Workers Compensation Insurer(s)For The Last Three(3) Years ____________________________________ _______________________________________________________
Insurance Agents Name _________________________________
Corresponding Periods Of Coverage In The Past Three(3) Years _______________________________________________________
Has This Business Been Issued An Experience Modification Factor For The Operations Conducted In Any Other State(s) _______________________________________________________
Do You, Or Will You, Send Any Of Your-Hired Workers To Perform Duties In Other States ____ Yes ____ No
If Yes, Such Employees Are Subject To State Jurisdiction. Please List These Other States _______________________________________________________
Do You, Or Will You, Have Employees Working Temporarily In Other States ____ Yes ____ NO
If Yes List These Other States _______________________________________________________ _______________________________________________________
If You Are From A Reciprocating State, Do You Elect To Cover Your Out Of State Hired Employees Through State Industrial Insurance While They Are Temporarily Working In this State ____ Yes ____ NO (If Yes The Wages Of These Employees Must Be Reported To the State Industrial Insurance Department For Premium Purposes And They May Also Be Reported To Your Home State Carrier)
Are You A Licensed Subcontractor ___ Yes ___ NO
If Yes License Name(s) ________________________________
If Yes License Number _________________________________
If Yes License Type ___________________________________
If Yes The Effective Date _____________________________
If You Are A Managing Owner, Do You Elect Worker’s Compensation Coverage For Yourself ___ Yes ___ No
Do You Want To Elect Coverage For Your Family Members Working In The Business ___ Yes ___ NO
If You Are or will be doing business with A State Agency, Please Provide The Agency’s Name ______________________________________________________
Contract Date ________________________________________
Does The Company Pay Any Of Its Officers For Rendered Services ___ Yes ___ NO
If Yes Name Of Officer(s) ____________________________
If Yes Title Of Officer(s) ___________________________
If Yes Nature Of Service _____________________________ ______________________________________________________
Company Officers or Managers Residing Outside And Are Not Rendering Any Service In this State Are Not Eligible For State Insurance Coverage Please List These Officers, If Any. ______________________________________________________ ______________________________________________________
State Insurance Coverage may be Elective For Those Employments Listed Below. If The Company Business Has Any Employees In this State's Categories And Wishes To Elect Coverage For Those Employees Please Check For Those Employees Please Check the Appropriate Blank Below Only To Elect Those Employment Categories. No Coverage may be available In this State or of Effect For These Categories Of Employment Unless Specifically Elected.
____ Clergy, Rabbi, Lay, Reader, or similar Person In The Service Of Church Or Religion.
____ Theatrical Or Stage Performers, Including Contract Performers.
____ Farming, Dairying, Agriculture, Horticulture, Stock Or Poultry Raising.
____ Household Domestic Employment(Ranch Cooks Are Included).
Please Estimate Your Payroll Based On Anticipated Employee Wages And Enter It In The Spaces Provided Below, If Provided, Include Cost Of Board And/or Room As Part Of Wages.
Board(Meals)__________________________________________
Room _________________________________________________
Clothing/Uniforms ____________________________________
Utilities ____________________________________________
Other ________________________________________________
Description Of Business ______________________________
Number Of Employees __________________________________
Monthly Payroll ______________________________________
This Business & Resulting Employment Of Staff Began, Or Will Begin On: ________________________________________
Provide The Name And Telephone Number Of The Business’s Contact For Workers’ Compensation. _______________________________________________________
Other Attachments(Explain And Indicate Number Of Pages): ______________________________________________________ ______________________________________________________
Trade Mark ___________________________________________
Service Mark _________________________________________
Copy Right ___________________________________________
Trade Name ____________________________________________
In Nevada:
The Following Supplemental Forms And Attachments Are Incorporated In The Application (SIIS-100) For Industrial Insurance Coverage In Addition To The Business Registration Form:
____ SIIS-105: Construction ____ SIIS-110: Ground Transportation ____ SIIS-115: Air Transportation ____ SIIS-120: Mining ____ SIIS-125: Manufacturing ____ SIIS-130: Mercantile ____ SIIS-135: Service Industry ____ SIIS-140: Farming/Ranching ____ SIIS-145:Stores/Warehousing ____ SIIS-150: Government ____ SIIS-155:Professional/Admin. Services ____ SIIS-160: Geophysical/Geological ____ SIIS-165: Health Care Facility ____ SIIS-175: Consulting Engineering ____ SIIS-180: Drilling ____ SIIS-185: Building Operations ____ SIIS-190:Hotel/Motel/Restaurant/ Bar/Casino ____ SIIS-195: Other ____ SIIS-200: Employee Leasing ____ SIIS-205: Joint Employee Leasing
Select A Managed Care Organization (MCO) For The Treatment Of Injured Workers.
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