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Business License Application

Entity Name
Type of License
License Number
Desc.
Requester Details
Entity Contact Name
Entity Address
City
State
ZIP
Phone
Email
Entity Desc.
Fed ID#
State ID#
Entity Activity Type
Applied Date (mm-dd-yyyy)
Date of Issue (mm-dd-yyyy)
Date of Expiry (mm-dd-yyyy)
Fee
Reference Item Type
Reference Item Number
Date (mm-dd-yyyy)
Fee Amount
Payment Method
Payment ID
Reversed Date (mm-dd-yyyy)
Reversed Amount
Description
Inspection Number
Attach Document (PDF, JPG, PNG, GIF, TIFF Only)


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