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CONTACT INFORMATION (This is where we will ship your documents)
First Name* :
Last Name* :
Address* :
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BUSINESS OVERVIEW
Is it a new business?
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Date of Formation* :
(mm/dd/yyyy)
Date Business Planning to Start* :
it can be a future date (mm/dd/yyyy)
Employer ID Number* :
Copy Address from Contact Information if same
Address* :
(P O BOX address is not acceptable)
Suite/Apt:
City* :
State* :
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Zip* :
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Business Type:
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Accommodation, Food Services & Drinking Places - Accommodation
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Rental and Leasing Services
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Retail Trade-Building Material & Garden Equipment & Supplies
Retail Trade-Building Material & Garden Equipment & Supplies Dealers
Retail Trade-Clothing & Accessories Stores
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Retail Trade-Miscellaneous Store Retailers
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Transportation & Warehousing-Couriers & Messangers
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Wholesale Trade-Merchant Wholesalers,Double Goods
Wholesale Trade-Merchant Wholesalers,Nondurable Goods
Wholesale Electronic Markets and Agents & Brokers
Unclassified Establishments
Business Description* :
Do you have any Felony?* :
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Yes
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Do you owe any Beer & Wine Taxex to the state?* :
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Yes
Please Explain:
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* :
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Yes
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Did you ever apply for the same busness?* :
No
Yes
Please Explain:
Are you adding a new location?* :
No
Yes
Please Explain:
Are you purchasing or acquiring an existing business?* :
No
Yes
Please Explain:
Sell products or services at retail (to consumers)?* :
No
Yes
Please Explain:
Sell products or services at wholesale (to registered dealers who will sell to consumers)?
* :
No
Yes
Please Explain:
Purchase or sell second hand goods?* :
No
Yes
Please Explain:
Do you own or rent the place?
Provide Lease/Occupancy License)* :
No
Yes
Please Explain:
OFFICERS/MEMBERS INFORMATION
OFFICER 1
Same as Contact Information
Full Name* :
Title* :
President
Vice President
Secratary
Treasurer
Owner
Member
Driving License Number:
(if any)
Driving License State:
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Social Security Number* :
(999-99-9999)
Percentage of Ownership* :
Date of Birth* :
(mm/dd/yyyy)
Hair Color?
Eyes Color?
Height?
Weight?
Race?
Residence Address* :
City* :
State* :
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Zip* :
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County* :
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Phone:
Fax:
OFFICER 2
OFFICER 3
PAYMENT INFORMATION
Same as Contact Information
First Name* :
Last Name* :
Billing Address* :
City* :
State* :
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Zip* :
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Phone* :
Fax:
Card Type* :
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Visa
Mastercard
Discover
American Express
Expiration Date* :
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02
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2019
2020
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Card Security Code* :
Please use the security code as follow:
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3. Discover Card- Please insert 3 digits security code from the back of the card
4. American Express- Please insert 4 digits security code from the front of American Express
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