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Ounty: Tel / Fax: ( ) ( ) - ) ( / - Website Address: Contact / Title: Contact Tel / Email: / / Business Description: Type of Entity: (e.g. Nonprofit, C-Corp, LLC) Number of Employees: (#Full Time+Part Time & Contractor Weekly Hours/35) Gross Revenue (Est): / Prior Fiscal Year Agent/Regional Representative: / Current Projected Year Projected for Next Year ) Tel: ( - Additional Required Information 1. Please indicate the type(s) of personally identifiable information ( P.

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Execute BIZLock Program Application within a couple of minutes following the recommendations below:

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