Arizona Department of Revenue

Attn: License & Registration

PO Box 29032
Phoenix, AZ 85038-9032

AZTaxes.gov Site Registration

Additional Instructions:
1. Print and complete signature card.
2. Mail completed signature card to the above address.

Part I Taxpayer Information

1. Fill out one of the following as it relates to the type of business:

(a). Federal Employer Identification Number

(b). Social Security Number 7 6 5 5 6 8 1 5 7

(c). State of Arizona Assigned Identification Number

2. Legal Business Name/Owner/Employing Unit

PHILAM ELECTRIC / GLENN M BONITA
____________________________________________________________________________________________

3. Business or DBA Name

PHILAM ELECTRIC
____________________________________________________________________________________________

Part II AZTaxes.gov Security Administrator Information

1. Name

Last First MI
BONITA
____________________________________ GLENN
__________________ M
___

2. Title: _____________________________

3. Social Security Number (optional): 7 6 5 5 6 8 1 5 7

glennmbonita@yahoo.com
4. E-Mail: _____________________________________
(602) 904-5644
5. Phone: ______________________________________

Part III Signature(s) By Individuals Legally Responsible for the Business

This signature card must be signed either by the sole owner, two partners, two corporate officers, two members and/or managing
members, the trustee, receiver or personal representative of an estate.

Under penalty of perjury I (we) declare that the information provided on the application completed on the AZTaxes.gov site is
true and correct. I (we) hereby authorize the security administrator listed in PART II to access the AZTaxes.gov site for the
business identified in PART I. This authority is to remain in full force and effect until the Arizona Department of Revenue
has received written termination notification from an authorized officer.

Type or Print Name Title Signature Date

GLENN M BONITA 1/18/2011

Type or Print Name Title Signature Date

For Department Use Only – Document Locator Number

11Z0185505024