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Employer ID No.: 2. Type of Ownership: - Proprietorship Corporation If a corporation, state of incorporation: or Proprietor s Social Security No.: LLC Partnership - Other (Identify) Fiduciary LLP - If Corporation or LLC, enter N.C. Secretary of State ID No., if applicable: 3. Legal Business or Owner s Name: I. Identifying Information 4. Trade Name (DBA Name): 5. Daytime Business Phone: 6. Fax Phone: 7. Business Location in N.C.: Street (Not P.O. Box Numbe.

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