Transcription of LIC2: License Application
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LIC2: License Application
Rev. 09/ 18 LIC2: License Application Application must be typewritten. License Number Section is used for: Changes, Renewals, and Reissues 4 Applicant Information Required for all applications . First Name: Middle Initial: Last Name: Home Address: Home Telephone: City: State: Zip: Mobile Telephone: Date of Birth (m/d/yy) *Social Security No.: E-Mail: Business Name Bus. E-mail: Office Address: Bus. Phone: City: State: Zip: 5a Primary Business Information 8 Partner or Officer Information (must list all partners or officers) Name: Address: Phone: City: State: Zip: Lic No: % Control: Title(s): Name: Address: Phone: City: State: Zip: Lic No: % Control: Title(s): Name: Address: Phone: City: State: Zip: Lic No: % Control: Title(s): Name: Address: Phone: City: State: Zip: Lic No: % Control: Title(s): 3 License Type New Renewal Reissue (Lost/Stolen) Change (ie: Address/Business/Deactivations) Reinstatement 1 Application Type 2 License Number Business Name Bus.
4 APPLICANT INFORMATION (required for all applications) Bus. Name: Bus. Email Bus. Address: Bus. Phone City: State Zip 5A (required for all applications)PRIMARY BUSINESS INFORMATION 6 5B SECONDARY BUSINESS INFORMATION LICENSE USE (choose one) Individual/Sole-Proprietor On Behalf of a Corporation On Behalf of a Partnership
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