Section 1 of 1 in this document

Licensee Information

Legal Entity Name

Assumed Name/Doing Business As Name (DBA)

Establishment Phone Number:

This email address below will be the main point of contact for all licensing and account questions or concerns. Renewals will be sent to this address. It is the responsibility of the business owner to ensure the email address on file is up-to-date.

To update the email address on file, please submit this form and the new email address to be added to the account.

Only ONE Email Address is Accepted per Establishment

Email Address for ALL COMMUNICATION:

PRIMARY CONTACT FOR ALL LICENSING INQUIRIES

This person will be contacted for all matters regarding the licensing account. Note in the event of an emergency the 24/7 contacts listed below will be contacted.

Primary Contact Phone Number

Do you have an extension to add?

Yes

Primary Contact Phone Number

LOCAL CONTACT FOR EMERGENCY PURPOSES

Local Emergency Contact Phone Number:

CONTACT FOR ENTITY'S LEGAL AGENT

Does the Entity have a Legal Agent?

Yes

Legal Agent's Office Name:

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.