Company Name
DBA(Doing Business AS)
Company Phone Number
Email
Type of Business Entity
State of Incorporation (applies to corporate entities only)
Company Address (P.O. Boxes are not acceptable)
Owner Address (P.O. Boxes are not acceptable)
Mailing Address
Does your business do any of the following: 1) own a highway motor vehicle weighing 55,000 pounds or more, 2) involve gambling, 3) sell or manufacture alcohol, tobacco, or firearms, 4) pay federal excise taxes, 5) received or applied for an EIN before, 6) currently have, or plan to hire employees within the next year
If Yes, Please Enter number(s) in which applies to your company
Business Description
Owner Information
Owner's Full Name
Owner's Social Security Number
FEDERAL PRIVACY ACT - Disclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identification of any individual affected by applicable law, 42 U.S.C. §405(c)(2)(C)(i)
Electronic Signature of Owner Signature Date
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