Intake Form – Multiple Member LLC (Premium)

	Member #1 (Responsible Party) Member #2 Member #3
Member’s Name:
Address:
Phone:
Email:
Last Four Digits of SSN:
Ownership Interest:
Registered Agent:	Registered Agent:
Name of Your Business: Confirm designation: LLC, Limited Liability Company, Ltd., etc.
Business Address:
Business Phone:
Business Email:
Business Website:
Effective Date:
Description of Business: If retail, please indicate whether it is a storefront or online
Is this a Professional Corporation? A corporation formed by a licensed individual (such as a doctor, dentist, engineer, architect, accountant, etc.)
Managed By:	Manager Name:
Officers:
Employees:	Number of Employees: Date for Wages:
Entity Tax Designation: “Default” is automatically treated as a partnership unless elected otherwise
Bank:
Accountant:
Insurance Agent:
Referred By:
Expedite Through Esquire Assist: * Additional Charge	Expedited Service:
Are you a Veteran or active reservist? A veteran is an individual who served in the United States Armed Forces, including a reserve component of the National Guard, and who was discharged or released from service under conditions other than dishonorable. A reservist is a member of a United States Armed Forces reserve component or National Guard.