Please note that, upon approval, a copy of this registration form along with your ID and Access Code will be mailed to the mailing
address specified above.
I, representative of the above mentioned company, hereby authorize the Department of Revenue & Taxation to register for a GuamTax
Online Account on the GuamTax.com web site. Under penalties of perjury, I declare that I have examined this registration form and
statement and to the best of my knowledge and belief, they are true, correct, and complete.
Name and Title
Sign
here
Signature Date
GuamTax.com
Date of Application
EIN/SSN Company Name
E-mail Address
Contact Person
Phone Number
Mailing Address
Do you already have a GuamTax user account? If so, account name:
Fax Number
Zip Code:
My company provides the following specialized service:
Payroll Processing
Vehicle Safety Inspection
Vehicle Insurance
Type of Vehicle Insurance Applicant:
Insurance Company
Agent/Subagent
(Check this if your company files SWICA for other businesses.)
(If checked, please complete Certification for Agent/Subagent
to the right.)
Certification for Agent/Subagent Only
We, the Undersigned Insurance Company, do hereby authorize the
Department of Revenue and Taxation to make available the following
option to the above Agent/Subagent.
Access all Vehicle Insurance Policies for the Insurance Company.
Access only the Vehicle Insurance Policies written by the above
mentioned Agent/Subagent.
Name of Insurance Company
Name of Authorized Representative
Date
Signature of Authorized Representative
For Department of Revenue and Taxation Sta Use Only
Employee Name:
Date Received:
Date Completed:
Assigned ID Number is: Assigned Access Code is:
Approved Disapproved
Post Office Box 23607, Guam Main Facility, Guam 96921 · Tel. / Telifon: (671) 635-1815 · Fax / Faks: (671) 633-2643
Registration Form for
Specialized Service Providers
Dipåttamenton Kontribusion yan Adu’ånå
DEPARTMENT OF
REVENUE AND TAXATION
GOVERNMENT OF GUAM Gubetnamenton Guåhan
MARIE M. BENITO, Acting Deputy Director
EDWARD J.B. CALVO, Governor Maga’låhi
RAY TENORIO, Lt. Governor Tiñente Gubetnadot
JOHN P. CAMACHO, Acting Director
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