Oregon Marijuana Tax Registration

Marijuana Tax Registration
Form OR-MTR, Oregon Marijuana Tax Registration, 150-610-002
Clear form

Form OR-MTR

Office use only

18270001010000
Oregon Department of Revenue

Page 1 of 1, 150-610-002
(Rev. 04-20-22, ver. 01)

Oregon Marijuana Tax Registration
Submit original form—do not submit photocopy

NOTE: A separate registration is required for each location selling recreational marijuana products.
Please print. See instructions.
Organization information
Recreational sales start date

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Federal employer identification number (FEIN)

OLCC retail license number

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Legal business name (licensed by OLCC)

Doing business as (DBA)

Type of ownership (check only one):

Corporation

Sole proprietorship (individual)

Sub-chapter S corporation

Partnership—general

Partnership—limited

LLP (limited liability partnership)
Other nonprofit

Non-profit 501(c)(3) (attach federal exemption)

OR a LLC (limited liability company) recognized by the IRS as a:
LLC—Corporation

OR

LLC—sole proprietorship

LLC Partnership

OR

LLC—disregarded entity

OR

Business phone

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Check if change in address

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Mailing address

City

State

ZIP code

Physical address (required)

City

State

ZIP code

Payroll information
Will your business have employees?

If yes, have you registered for a payroll account?

If yes, please provide business identification number (BIN)

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Yes

No

Yes

No

Owners, officers, partner information
List all owners, officers, or partners. Please print clearly, (use additional sheets if necessary).
Name

Social Security number (SSN)

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Address

State

City

Name

SSN

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Address

State

City

Contact person
Name

Title

Daytime phone

Email

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–

Submitted by
Signature

X

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ZIP code

Print name signed above

Date

Phone

/

/

Title

Mail your completed form to:	 Oregon Department of Revenue, PO Box 14630, Salem OR 97309-5050
Or email to:	
[email protected]
Or fax to:	
503-945-8772

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ZIP code