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COUNTY OF CAYUGA – COUNTY TREASURER’S OFFICE HOTEL/MOTEL TAX 160 Genesee St., 5th Floor Auburn, NY 13021 Telephone: [PHONE REDACTED] CERTIFICATE OF REGISTRATION And Application for Certificate of Authority to collect Hotel/Motel Room Occupancy Tax All questions must be answered Please print or Type 1. Business Name: (Individual, Trade Name, or Corporate Name) 2. Mailing Address: (Street) (City) (State) (Zip) 3. Location of Business: (Street) (City) (State) (Zip) 4. List Below Name and Home Address of Individual, Partners or Principal Officers (If Corp.): NAME HOME ADDRESS TITLE 5. Type of Establishment: Hotel Motel Other (Specify) 6. Type of Ownership: Individual Partnership Corporate 7. Date started business in Cayuga County: (if subsequent to January 1, 1995) 8. If acquired from former owner after January 1, 1995: Name under which it operated The Registration Number 9. Number of places of business (or branches) that applicant conducts in Cayuga County: 10. If more than one branch of the same business conducted, do you prefer to file a Consolidated Return OR a Separate Return for each location I hereby CERTIFY that the statements made herein have been examined by me, and are to the best of my knowledge and belief, true and complete. DATE NAME TITLE ID. No. H- ---PAGE BREAK--- REGISTRATION The Legislature of the County of Cayuga has provided by Local Law as follows: Every hotel/motel operator shall file with the Cayuga County Treasurer a certificate of registration in a form prescribed by the Treasurer. The Treasurer shall thereafter issue without charge to each hotel/motel operator a certificate evidencing the authority of such operator each additional place of business of such operator. Each certificate or duplicate shall state the place of business to which it is applicable. PENALTIES Any hotel/motel operator willfully failing to file a registration certificate or surrender the certificate of authority as required or assigning or transferring such certificate of authority, shall be liable to the penalties provided by law. SCHEDULE OF LOCATIONS TRADE NAME LOCATION CERTIFICATE NO.