Company Name:

        First Name:

       Last Name:

Company Status
                               (corporation, LLC, Sole Proprietary, Partnership)

               Corporation State:

If Foreign Corp., what state:

                                 D&B # 

                                  FEIN #

                                       SS# 

                    Person Credit: (Score)

                License Type & #

           Locality for License:

Corporate Name as shown on articles:

Date Business established / started: (Not all businesses start out incorporated)

             Date Business incorporated:

Do you sell on the Internet?: Yes or No. 
If yes, what percentage of sales are from the Internet?

Does your state require a professional license for your company?  Yes or  No
If so, please put the name of the license required and the
state contact information for verification in the box below.


          Street Address:

       City, State, Zip: 

     Company. Phone:

          Company Fax:

Is this business residential or commercial and what is the footage, floor number and/or number of stories?
What type of building (i.e. Brick, concrete, etc):
Only post answers that apply to your situation.

Company website:

      Contact email:

Nature of business:

                      SIC:   (To find code CLICK HERE) Once you get SIC code hit "Back" button

             Total sales (Revenue Last Year)

How you bill your customers:
(cash, check or credit card, Net 7 days, Net 10 days, Retainer plus additional billings, contractual basis,
Fee basis, require a deposit

Your customers: (check all that apply)
Manufacturer   Wholesalers     Retailers     Government    General public    Non-profit organizations 
Commercial concerns

                               Number of employees :

Does this business have a fictitious name:
If yes, where was it filed:

Ownership Name CEO, President and percentage of stock:


 

Affiliate Name:

Affiliate Phone:

All the information above must be completed.

COMMENTS: Special instructions or additional information