#1 Legal Business Name

#2 Email

#3 Business Website

#4 Business Type? (Choose one) Co-operative Corporation Limited Liability Company or Sole Proprietorship Non Profit Corporation Partnership

#5 Business Registration Number (EIN)

#6 Business Address

#7 Authorize Representative Details ( First Name & Last Name)

**#8 Job Position (**Choose one) Director VP CFO GM CEO General Counsel

#9 Phone Number