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2. Are you changing your business name on your business license?

   1. Yes
   2. No
4. New or Current Business Name*
5. Previous Business Name
7. Account Number*
8. Effective Date of Business Name Change*
   Effective Date of Business Name Change
10. Do you have an updated Business description?*

    1. Yes
    2. No
12. Updated Business Description*
14. Did the location / physical address of your business change?*

    1. Yes
    2. No
15. Effective Date of Location Change*
    Effective Date of Location Change
17. New Street Address*
19. City*
20. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
21. Zip Code*
25. Previous Street Address*
27. City*
28. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
29. Zip Code*
31. Did your mailing address change?*

    1. Yes
    2. No
33. Updated Mailing Address*
35. City*
36. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
37. Zip Code*
41. Previous Mailing Address*
43. City*
44. State*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
45. Zip Code*
47. Business Phone Number*
48. Email Address*
50. After Hours Emergency Contact*
52. Electronic Signature*

    Type your name in the box to certify this information is true and correct to the best of your knowledge.

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54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

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