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Member #1 (Responsible Party)Member #2Member #3
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Member’s Name:
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Address:
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Phone:
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Email:
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Last Four Digits of SSN:
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Ownership Interest:
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Registered Agent:
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[group group1]
Registered Agent:
[/group]
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Name of Your Business: Confirm designation: LLC, Limited Liability Company, Ltd., etc.
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Business Address:
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Business Phone:
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Business Email:
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Business Website:
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Effective Date:
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Description of Business: If retail, please indicate whether it is a storefront or online
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Is this a Professional Corporation? A corporation formed by a licensed individual (such as a doctor, dentist, engineer, architect, accountant, etc.)
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Managed By:
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[group group4]
Manager Name:
[/group]
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Officers:
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Employees:
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[group group2]
Number of Employees:
Date for Wages:
[/group]
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Entity Tax Designation: “Default” is automatically treated as a partnership unless elected otherwise
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Bank:
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Accountant:
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Insurance Agent:
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Referred By:
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Expedite Through Esquire Assist: * Additional Charge
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[group group3]
Expedited Service:
[/group]
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