Shareholder’s Name:
Address:
Phone:
Email:
Last Four Digits of SSN:
Registered Agent:
NoYes
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.)
Employees:
Number of Employees:
Date for Wages:
Bank:
Accountant:
Insurance Agent:
Referred By:
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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.
