Type of Ownership *: Select a Ownership Type Individual Partnership LLC Corporation  
Company Name *: Store Owner/Partner/Manager *: Type of Establishment *: Full Service Grocery Store Convenience Store Other Registered Legal Agent Representing Business (as filed with the Secretary of State) *: Registered Agent Address 1 *: Registered Agent Address 2: Registered Agent City *: Registered Agent State *: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Registered Agent Zip Code *: Registered Agent Phone Number *: Employer ID Number/ Federal Tax ID Number (IF SSN, LEAVE BLANK) *: Email Address *:

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