| | Member #1 (Responsible Party) Member #2 Member #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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| 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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| Officers: | |
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| Employees: | |
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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 | Expedited Service:
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