Application for Tax Agent Form

License DT-1017
TAX AGENTS (This Form may be used by all Individuals and Non-individuals who wish to
REGISTRATION be registered as Tax Agents, renew Tax Agent registration or amend Nominee Toll Free Number
details.
0800117000
COMMITTEE Please answer in CAPITAL letters where applicable and sign the declaration.
If you have any query regarding any of the questions consult the nearest
URA tax office for guidance. 08 2016

Section A- Identifying Information

1) Tick the appropriate box

First Time Registration Renewal Amendment

2) Applicant Type Individual Non-Individual

3) Full Name of Applicant as it appears at TIN registration 4) TIN

5) Taxpayer’s Physical Address

a) Plot Number b) Street Name c) Building Name

d) Trading Center e) District/City f) County/Municipality

g) Sub-County/Town Council/Division h) Village/Local Council/Zone

6) In case of renewal, indicate Date of Expiry of previous/ / /20

current License:

7) In case of amendment, indicate reasons for amendment

8) Have you ever had to appeal to be licensed? If Yes, give reasons

Yes No

9) Have you or your nominees ever been convicted of any If Yes, give details of the offence and conviction.
criminal offence?
Yes No

Section B – Individual Details /Nominee(s) for Non-Individual applicants

S.N Non-Individual Applicant Individual
Nominee 1 Nominee 2 Applicant
1. Name of Nominee

2. TIN of Nominee
3. Designation

4. Add Remove Add Remove

5. Attachments (Only where you have selected option to Add in 4 above):
a. Profile of Nominee (CV)
b. Academic Certificates
c. Professional Certificate
d. Identification
This section is not applicable for applicants who are renewing their registration.

Section C– Other Attachments

Payment Registration Receipt

Tax Clearance Certificate
Others, specify;
Section D- Reference for Work Done

Client Name TIN Service Provided Period of service

(dd/mm/yyyy to dd/mm/yyyy)
1.
2.
3.

(At least 2 persons you have done agency work for in the last 2 years)
Section E- Declaration and Certification
I declare that the information given on this application is true and correct and that 3) Printed Name of Signatory
failure to provide correct information may result in delayed processing or
rejection of this application (If this form is signed by a person other than the
applicant, formal powers of attorney will be required)
1) Authorized Signature 4) Position Held

2) Date signed (Day/Month/Year) 5) Contact Telephone Number

For Sections B, if you are declaring information of more than the individuals provided for, please use a
separate sheet in the same format as provide in the section.
Notes: For individual applicants, Select the other
select only the attachments attachments accompanying
Section A- Identifying
to be submitted along with the application.
Information.
the application.
The Tax Clearance
Provide your identification
For non-individual Certificate and Payment
information and specify the
applicants, specify the Registration Notice are
type of registration you
details of at least one mandatory.
have applied for.
nominee who is either an
Section D – Reference of
For Renewal you should employee, director or
Agency works done.
specify the expiry date of partner and also specify the
your previous or current attachments available for The applicant must provide
license. each nominee. details of any services
performed in the past period
You should submit the For either categories, if you
and the details of the client.
application for renewal 21 have provided a
days before expiry of your Professional certificate then
license. the Academic Certificates
are not required. Section E- Declaration
For Amendment you should and Certification
fill in the fields for which you The section is not
applicable at renewal. The application should be
want to amend.
certified by the applicant or
an authorized person before
submission of the
Section B- Individual Section C- Other
application to the nearest
Details. Attachments.
DT office.
Attachment for Individual Profiles.
Profile of Individuals/ Nominees

Name of Individual
Sn. Details
1. Qualifications (Provide details in part A if applicable otherwise provide details in B)
A. Professional Certificate/license/membership (i.e issued by ICPAU, ULS, any other professional body)
Profession Name of Issuing Institution/Body Reference/Certificate Number
Legal/ Accountancy/ Tax
Agents body

B. Under graduate or Post graduate awards (To be completed for individuals without the certification in A)
Qualification Attained Awarding Institution

2. Work Experience (Relevant experience to Tax Agency services)

Name of Employer/ Entity Position Held Responsibilities Period of service
(dd/mm/yyyy to
dd/mm/yyyy)

This is the format that should be used to declare the information relating to an individual applicant or the
nominees of a non-individual applicant. This shall be filled out for each individual declared in the main
application.
To be filled out for first time registration or amending to add another nominee.