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Get (If You Need Additional Space, Please Attach A Separate Sheet

Note: Complete all blocks, except shaded areas. Write N/A (not applicable) in those blocks that do not apply. 1 Name and address of business 2 Business phone number ( ) 3 (Check appropriate box) Other (specify) Sole proprietor Partnership Corporation County 4 Name and title of person being interviewed 5 Employer identification number 6 Type of business 7 Information about owner, partners, officers, major shareholder, etc. Effective Date Name and Title Section I 8 Latest filed i.

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