For Office Use Only

STD

APPLICATION FOR INCORPORATION

OF A NEVADA IC -DISC

Please complete the following and return it to Export Assist at 44 Montgomery Street, Suite 4050, San
Francisco, CA 94104 (T:800-894-8366). Additional information may be included on an attached sheet.

U.S. EXPORTER INFORMATION

Name: __________________________________________________ Title: _____________________________
Company: _______________________________________________ Phone: ___________________________
Address: __________________________ ______________________

Fax: ______________________________

City, State, Zip: ___________________________________________ E-mail: ____________________________

Do you wish Export Assist to work with your outside professional advisor? Yes ____ No ____
If yes, please complete the following:

C PA _ _ _ _

Attorney ____

Name: _______________________ ___________________________ Title: __ ________________________

Company: _______________________________________________ Phone:_________________________
Address: ________________________________________________ Fax: ___________________________
City, State , Zip: __________________________________________ E-mail: _________________________
1)

Description of export business activity:_______________ _ ___________________________ _______________

Primary countries to which you export: _________________________________________________________

2)

Ownership: Publicly-traded ____

3)

Structure: C Corp ____

Privately-held ____; if privately-held, total number of owners: ___ ______

S C orp ____

LLC ___ _

P artn ers hi p ____

Sole Owner ____ _

Co -Op _____

State of incorporation or organization: _______________________

4)

D a te o f fi s c a l y e a r e n d : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

5)

Are the members of this owners group currently operating or have in existence an Interest Charge Domestic
International Sales Corporation (IC -DISC)? Yes ____ No ____

6)

A r e t h e r e a n y i n d i v i d u a l o r c o rp o r a t e f o r e i g n s h a re h o l d e r s ? Y e s _ _ _ _
If y e s , h o w m a n y ? _ _ _ _ _ _

SPEC

COM SE R B/S

N o _ __ _

Percent of ownership for each: _ _ ___ ________________________________

7)

Do you import components for your export products? Yes _ ___ No _ ___ ; if yes, _ _ __% of total export s a l e s .

8)

IRS Service Center (city and state) where exporter files its Federal income tax return: _ _ _ _ __ _______________

9)

Shareholder name(s), permanent residence address and percentage of interest:

Na m e:_____________________________________ ___ _____________________ % of Interest: __ __________
Address: _______ ________________ ___________________________________________________________
Name:________________________________________ _____________________ % of Interest: __ __________
Address: __________________________________________________________________________________
N a m e:_____________________________________________________________ % of Interest: __ __________
Address: __________________________________________________________________________________

080107

FISC

IC-DISC INFORMATION
1)

Proposed name of IC -DISC: ______________________________________________________ _ ____________

( M u s t i n c l ud e a c o r po r a te e n d i ng , i . e . I n c o r p o ra t e d , C o r po r a t io n , C o m pa n y or a n a b b re v i at i o n , i . e . I n c . )

List two (2) alternatives: ________________________________________ ______________________________

_________________________________________________ _ ___________ _________
2)

Mailing address of IC -DISC: 1802 North Carson Street, Suite 212, Carson City, NV 89701

3)

Telephone: 8 0 0-8 9 4-8 3 66

4)

Authorized shares (common, $1.00 par value per share):

5)

Shareholder:______________________________________ ________ _____ U.S. SS# : ___________________

Fax: 8 8 8 -8 9 4-8366
2,500

Other: ________________ _ _________

(Select a number that is even ly divisible by the number of proposed shareholders. Mus t be at leas t 2,50 0.)

Permanent Residence: ________________ __________________ ____ _________________ % of Interest: ____

Shareholder:___________________________________ _____________ _ __ U.S. SS#: ___________________
Permanent Residence: ________________ _ ________ ______________________________ % of Interest: ____

S hould it b e IRA-own ed , i nclud e:

Tr a d i ti o n a l IR A

R oth IRA

Beneficiary/Owner: ________________________________________________ Telephone: ____________ __ _ _

Custodian Contact: _______________________________ ________________ Telephone: ________________

( U s e a s e p a ra t e s he e t f o r a d d it i o na l sh a r e h ol d e r in f o rm a t io n . )

6)

Total paid-in capital of the IC -DISC:

$2,500

Other: $__ _ __ _____________________

7)

Nam e(s) of director(s) of the IC -DISC: _ _ _______________ ___________________ _______________________

_____________________________________________________________ _____________________________
____________________________________________________ _________ _____________________________

(A t l e a s t o n e d i r ec t o r i s r e q u i r ed . )
8)

N a m e ( s ), t i t l e s a n d s o c i a l s e c u r i t y n u m b e r( s ) o f o f f i c e rs o f t h e I C - D I S C :
President: ___________________ _______________ ______ ____ _ __ _ U.S. SS#: ____________ ___________
Secretary: ________________________ _ __ _________ ______ __ __ _ _ U.S. SS#: _____________ __________
Treasurer: _______________________ ___________________ ______ U.S. SS#: _____________ __________

( S h o u l d h a v e a t l e a s t a P r e s i d e n t , S e c r e t a r y a n d T r e a s u r e r , a l l o f wh o m m a y b e t h e s a m e p e r s o n .)

INFORMATION FOR U.S. TAX IDENTIFICATION NUMBER OF IC -DISC (Form SS-4)

1)

D a t e o f f i s c a l y e a r e n d (m u s t b e s a m e a s s h a r e h o l d e r s ):
D ec em be r 3 1

2)

Other, please specify: ______________ _______________________________________

If a Buy/Sell IC -DISC, to whom does it sell its products/services:

R e ta i l ( p u b l i c )

Wh o l e s a l e ( b u s i n e s s e s )

Other, please specify: __________________________ _ ___________ ________________

An authorized signature provides Export Assist with consent to proceed with your incorporation request for a
Managed IC -DIS C. A n y cha n g es t o you r corporate legal structure (i.e., change from C to S corporation) must be
r e p o r t e d to E x p o r t A ss i s t , I n c . p r i or t o c h a n ge du e t o p o te n t ia l t a x r am i f i c a t i o n s.
Authorized Signature: _____ ______________________ ___ ______ _ ___________ Date: _ _ _ _ ______ __________
Name (please print): ____________________________________ __________ ____ Title: ______ _ __ _ __________

080107